Roxburgh Common Skin Diseases

ROXBURGHS
Common Skin Diseases

17th Edition
Ronald Marks
Emeritus Professor of Dermatology and
Former Head of Department of Dermatology
University of Wales College of Medicine
Cardiff, UK
Clinical Professor
Department of Dermatology and Skin Surgery
University of Miami School of Medicine
Miami, USA
Hodder Arnold
A member of the Hodder Headline Group London

http://bookmedico.blogspot.com
First published in Great Britain in 2003 by

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2003 Arnold
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the drugs recommended in this book.
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Contents
Preface
viii
1 An introduction to skin and skin disease

An overview
Skin structure and function
Summary
1
1
2
11
2 Signs and symptoms of skin disease

Alterations in skin colour
Alterations in the skin surface
The size, shape and thickness of skin lesions
Oedema, uid-lled cavities and ulcers
Secondary changes
Symptoms of skin disorder
Summary
12
12
14
15
17
19
20
23
3 Skin damage from environmental hazards

Damage caused by toxic substances
Injury from solar ultraviolet irradiation
Chronic photodamage (photoageing)
Summary
25
26
27
29
35
4 Skin infections
Fungal disease of the skin/the supercial mycoses/infections
with ringworm fungi (dermatophyte infections)
Bacterial infection of the skin
Viral infection of the skin
Summary
37
5 Infestations, insect bites and stings

Scabies
Pediculosis
Insect bites and stings
Helminthic infestations of the skin
Summary
58
58
63
65
69
70
37
44
50
56
iii
Contents
6 Immunologically mediated skin disorders

Urticaria and angioedema
Erythema multiforme
Erythema nodosum
Annular erythemas
Autoimmune disorders
Systemic sclerosis
Morphoea
Dermatomyositis
The vasculitis group of diseases
Blistering diseases
Dermatitis herpetiformis
Epidermolysis bullosa
Pemphigus
Drug eruptions
Summary
71
71
75
77
77
77
80
82
83
84
87
89
90
91
92
95
7 Skin disorders in AIDS, immunodeciency and venereal disease

Infections
Skin cancers
Other skin manifestations
Psoriasis
Treatment of skin manifestations of AIDS
Drug-induced immunodeciency
Other causes of acquired immunodeciency
Congenital immunodeciencies
Dermatological aspects of venereal disease
Summary
97
98
99
99
100
100
100
101
101
102
104
8 Eczema (dermatitis)
Atopic dermatitis
Seborrhoeic dermatitis
Discoid eczema (nummular eczema)
Eczema craquele (asteatotic eczema)
Lichen simplex chronicus (circumscribed neurodermatitis)
Contact dermatitis
Venous eczema (gravitational eczema; stasis dermatitis)
Summary
105
105
114
117
118
119
121
125
126
9 Psoriasis and lichen planus

Psoriasis
Pityriasis rubra pilaris
Lichen planus
Summary
128
128
142
144
147
iv
Contents
10 Acne, rosacea and similar disorders

Acne
Rosacea
Perioral dermatitis
Summary
149
149
162
168
169
11 Wound healing and ulcers

Principles of wound healing
Venous hypertension, the gravitational syndrome and venous ulceration
Ischaemic ulceration
Decubitus ulceration
Neuropathic ulcers
Less common causes of ulceration
Diagnosis and assessment of ulcers
Summary
171
171
173
177
178
179
180
182
182
12 Benign tumours, moles, birthmarks and cysts

Introduction
Tumours of epidermal origin
Benign tumours of sweat gland origin
Benign tumours of hair follicle origin
Melanocytic naevi (moles)
Degenerative changes in naevi
Vascular malformations (angioma)/capillary naevi
Dermatobroma (histiocytoma, sclerosing haemangioma)
Leiomyoma
Neural tumours
Lipoma
Collagen and elastic tissue naevi
Mast cell naevus and mastocytosis
Cysts
Treatment of benign tumours, moles and birthmarks
Summary
183
183
184
186
188
188
192
194
197
198
199
200
200
201
202
204
205
13 Malignant disease of the skin

Introduction
Non-melanoma skin cancer
Melanoma skin cancer
Lymphomas of skin (cutaneous T-cell lymphoma)
Summary
207
207
207
219
224
226
14 Skin problems in infancy and old age

Infancy
Old age
Summary
227
227
233
237
v
Contents
15 Pregnancy and the skin

Physiological changes in the skin during pregnancy
Effects of pregnancy on intercurrent skin disease
Effects of intercurrent maternal disease on the fetus
Skin disorders occurring in pregnancy
Summary
238
238
240
240
241
242
16 Disorders of keratinization and other genodermatoses

Introduction
Xeroderma
Autosomal dominant ichthyosis
Sex-linked ichthyosis
Non-bullous ichthyosiform erythroderma
Bullous ichthyosiform erythroderma (epidermolytic hyperkeratosis)
Lamellar ichthyosis
Collodion baby
Other disorders of keratinization
Other genodermatoses
Summary
243
243
245
246
247
249
251
252
252
254
256
257
17 Metabolic disorders and reticulohistiocytic proliferative disorders

Porphyrias
Necrobiotic disorders
Reticulohistiocytic proliferative disorders
Summary
259
259
265
266
267
18 Disorders of hair and nails

Disorders of hair
Disorders of the nails
Summary
268
268
276
279
19 Systemic disease and the skin

Skin markers of malignant disease
Endocrine disease, diabetes and the skin
Skin infection and pruritus
Androgenization (virilization)
Nutrition and the skin
Skin and the gastrointestinal tract
Hepatic disease
Systemic causes of pruritus
Summary
281
281
285
288
289
291
292
292
293
293
20 Disorders of pigmentation
Generalized hypopigmentation
Localized hypopigmentation
295
296
297
vi
Contents
Hyperpigmentation
Summary
299
302
21 Management of skin disease

Psychological aspects of skin disorder
Skin disability
Topical treatments for skin disease
Surgical aspects of the management of skin disease
Systemic therapy
Phototherapy for skin disease
Summary
303
303
305
305
309
311
314
316
Bibliography
317
Index
319
vii
Preface
Recognition and treatment of skin disease is an important part of the practice of
medicine. These skills should form an essential part of the undergraduate curriculum because skin disorders are common and often extremely disabling in one
way or another. Apart from the fact that all physicians will inevitably have to cope
with patients with rashes, itches, skin ulcerations, inamed papules, nodules and
tumours at some point in their careers, skin disorders themselves are intrinsically
fascinating. The fact that their progress both in development and in relapse can be
closely observed, and their clinical appearance easily correlated with their pathology, should enable the student or young physician to obtain a better overall view
of the way disease processes affect tissues.
The division of the material in this book into chapters has been pragmatic,
combining both traditional clinical and disease process categorization, and after
much thought it seems to the author that no one classication is either universally
applicable or completely acceptable.
It is important that malfunction is seen as an extension of normal function
rather than as an isolated and rather mysterious event. For this reason, basic structure and function of the skin have been included, both in a separate chapter and
where necessary in the descriptions of the various disorders.
It is intended that the book full both the educational needs of medical students and young doctors as well as being of assistance to general practitioners in
their everyday professional lives. Hopefully it will also excite some who read it sufciently to want to know more, so that they consult the appropriate monographs
and larger, more specialized works.
In this new edition of Roxburghs Common Skin Diseases account has been taken
of recent advances both in the understanding of the pathogenesis of skin disease
and in treatments for it. Please forgive any omissions as events move so fast it is
really hard to catch up!
viii
C H A P T E R
An introduction to skin
and skin disease
An overview
Summary
11
An overview
Skin is an extraordinary structure. We are absolutely dependent on this 1.7 m2 of
barrier separating the potentially harmful environment from the bodys vulnerable
interior. It is a composite of several types of tissue that have evolved to work in
harmony one with the other, each of which is modied regionally to serve a different function (Fig. 1.1). The large number of cell types (Fig. 1.2) and functions of
the skin and its proximity to the numerous potentially damaging stimuli in the
environment result in two important considerations. The rst is that the skin is
frequently damaged because it is right in the ring line and the second is that
Stratum corneum
SC (15 m)
E (3550 m)
Granular cell layer
HF
D (12 mm)
ESG
SFL
Malpighian layer
Figure 1.1 Simple three-dimensional plan view of the

skin. HF hair follicle; ESG eccrine sweat gland;
SC stratum corneum; E epidermis; D dermis;
SFL subcutaneous fat layer.
Basal layer
Figure 1.2 Diagram of the basic structure of the

epidermis.
1
An introduction to skin and skin disease
each of the various cell types that it contains can go wrong and develop its own
degenerative and neoplastic disorders. This last point is compounded by the ready
visibility of skin, so that minor deviations from normal give rise to a particular set
of signs. The net effect is that there seems to be a large number of skin diseases.
Skin disease is very common. However healthy we think our skin is, it is likely
that we will have suffered from some degree of acne and maybe one or other of
the many common skin disorders. Atopic eczema and the other forms of eczema
affect some 15 per cent of the population under the age of 12, psoriasis affects 12
per cent, and viral warts, seborrhoeic warts and solar keratoses affect large segments of the population. It should be noted that 1015 per cent of the general
practitioners work is with skin disorders, and that skin disease is the second commonest cause of loss of work. Although skin disease is not uncommon at any age,
it is particularly frequent in the elderly.
Skin disorders are not often dramatic, but cause considerable discomfort and
much disability. The disability caused is physical, emotional and socioeconomic,
and patients are much helped by an appreciation of this and attempts by their
physician to relieve the various problems that arise.

It is difcult to understand abnormal skin and its vagaries of behaviour without
some appreciation of how normal skin is put together and how it functions in
health. Although, at rst glance, skin may appear quite complicated to the uninitiated, a slightly deeper look shows that there is a kind of elegant logic about its
architecture, which is directed to subserving vital functions.
THE SKIN SURFACE

The skin surface is the delineation between living processes and the potentially
injurious outside world and has not only a symbolic importance because of this,
but also the important task of preventing and controlling interaction between the
outside and the inside. Its 1.7 m2 area is modied regionally to enable it better to
perform particular functions. The limb and trunk skin is much the same from site
to site, but the palms and soles, facial skin, scalp skin and genital skin differ somewhat in structure and detail of function. The surface is thrown up into a number
of intersecting ridges, which make rhomboidal patterns. At intervals, there are
pores opening onto the surface these are the openings of the eccrine sweat
glands (Fig. 1.3). The diameter of these is approximately 25 m and there are
approximately 150350 duct openings per square centimetre (cm2 ). The hair follicle
openings can also be seen at the skin surface and the diameter of these orices and
the numbers/cm2 vary greatly between anatomical regions. Close inspection of the
follicular opening reveals a distinctive arrangement of the stratum corneum cells
around the orice.
At magnications of 5001000 times, as is possible with the scanning electron
microscope (SEM), individual horn cells (corneocytes) can be seen in the process
2
Figure 1.3 Diagram of the skin surface to show sweat

pores and hair follicle openings.
Figure 1.4 Scanning electron micrograph of stratum

corneum showing a cell in the process of desquamation.
Figure 1.5 Photomicrograph of a corneocyte (150).
Figure 1.6 Photomicrograph of cryostat section of

epidermis to show the delicate structure of the stratum
corneum (90).
of desquamation (Fig. 1.4). Corneocytes are approximately 35 m in diameter,

1 m thick and shield like in shape (Fig. 1.5).
THE STRATUM CORNEUM

Also known as the horny layer, this structure is the differentiated end-product of
epidermal metabolism (also known as differentiation or keratinization). The nal
step in differentiation is the dropping off of individual corneocytes in the process
of desquamation seen in Figure 1.4. The horny layer is not well seen in routine
formalin-xed and parafn-embedded sections. It is better observed in cryostatsectioned skin in which the delicate structure is preserved (Fig. 1.6). It will be noted
that at most sites there are some 15 corneocytes stacked one on the other and that
the arrangement does not appear haphazard, but is reminiscent of stacked coins.
The corneocytes are joined together by the lipid and glycoprotein of the intercellular cement material and by special connecting structures known as desmosomes.
3
The orderly release of corneocytes at the surface in the process of desquamation

is not completely characterized, but appears to depend on the dissolution of the
desmosomes by a chymotryptase protease enzyme near the surface, which is activated by the presence of moisture. On limb and trunk skin, the stratum corneum is
some 1520 cells thick and, as each corneocyte is about 1 m thick, it is about
1520 m thick in absolute terms. The stratum corneum of the palms and soles is
about 0.5 mm thick and is, of course, much thicker than that on the trunk and limbs.
The stratum corneum prevents water loss and when it is deranged, as, for
example, in psoriasis or eczema, water loss is greatly increased so that severe dehydration can occur if enough skin is affected. It has been estimated that a patient
with erythrodermic psoriasis may lose 6 L of water per day through the disordered
stratum corneum, as opposed to 0.5 L normally.
The stratum corneum also acts as a barrier to the penetration of chemical agents
with which the skin comes into contact. It prevents systemic poisoning from
skin contact, although it must be realized that it is not a complete barrier and
percutaneous penetration of most agents does occur at a very slow rate. Those
responsible for formulating drugs in topical formulations are well aware of this
rate-limiting property for percutaneous penetration of the stratum corneum and
try to nd agents that accelerate the movement of drugs into the skin.
The barrier properties are, of course, also of vital importance in the prevention
of microbial life invading the skin once again the barrier properties are not
perfect, as the occasional pathogen gains entry via hair follicles or small cracks
and ssures and causes infection.
The mechanical qualities of the stratum corneum are also of great importance.
The structure is very extensible and compliant in health, permitting movement of
the hands and feet, and is actually quite tough, so that it provides a degree of
mechanical protection against minor penetrative injury.
THE EPIDERMIS
The epidermis contains keratinocytes mainly, but also non-keratinocytes
melanocytes and Langerhans cells. This cellular structure is some three to ve
cell layers thick on average, 3550 m thick in absolute terms (Fig. 1.7a). Not
unexpectedly, the epidermis is about two to three times thicker on the hands and
feet particularly the palms and soles. The epidermis is indented by nger-like
projections from the dermis known as the dermal papillae (Fig. 1.7b) and rests on
a complex junctional zone which consists of a basal lamina and a condensation of
dermal connective tissue (Fig. 1.8).
The cells of the epidermis are mainly keratinocytes containing keratin tonolaments, which are born in the basal generative compartment and ascend through
the Malpighian layer to the granular cell layer. They are joined to neighbouring
keratinocytes by specialized junctions known as desmosomes. These are visible as
prickles in formalin-xed sections but as alternating light and dark bands on
electron microscopy. In the granular layer, they transform from a plump oval or
rectangular shape to a more attened prole and lose their nucleus and cytoplasmic
4
(a)
(b)
Figure 1.7 (a) Photomicrograph of normal epidermis (H & E, 90). (b) Photomicrograph of the underside of a sheet
of epidermis after removal from dermis showing the indentations made by the nger-like dermal papillae.
The Basal Lamina

Sub basal
dense plaque
Anchoring
filaments
Anchoring fibril
Collagen fibre
Tonofilaments
Attachment plaque
Plasma membrane
Lamina lucida
Basal lamina
Dermal microfibril
bundle
Figure 1.8 Diagram to

show the junctional zone
between epidermis and
dermis.
organelles. In addition, they develop basophilic granules containing a histidinerich protein known as laggrin and minute lipid-containing, membrane-bound
structures known as membrane-coating granules or lamellar bodies.
These alterations are part of the process of keratinization during which the
keratinocytes differentiate into tough, disc-shaped corneocytes. Other changes
include reduction in water content from 70 per cent in the keratinocytes to the
stratum corneums 30 per cent, and the laying down of a chemically resistant,
cross-linked protein band at the periphery of the corneocyte.
Of major importance to the barrier function of the stratum corneum is the intercellular lipid which, unlike the phospholipid of the epidermis below, is mainly polar
ceramide and derives from the minute lamellar bodies of the granular cell layer.
It takes about 28 days for a new keratinocyte to ascend through the epidermis
and stratum corneum and desquamate off at the skin surface. This process is
greatly accelerated in some inammatory skin disorders notably psoriasis.
Pigment-producing cells
Black pigment (melanin) synthesized by melanocytes protects against solar ultraviolet radiation (UVR). Melanocytes, unlike keratinocytes, do not have desmosomes,
5
Dendrites
Nucleus
Nucleolus
Developing melanosomes
stages IIV

show a melanocyte with
dendrites injecting
melanin into
keratinocytes.
but have long, branching dendritic projections that transport the melanin they
synthesize to the surrounding cells (Fig. 1.9). They originate from the embryonic
neural crest. Melanocytes account for 510 per cent of cells in the basal layer of the
epidermis. Melanin is a polymer, synthesized from the amino acid tyrosine with
the help of a copper-containing enzyme, tyrosinase. Exposure to the sun accelerates
melanin synthesis, which explains suntanning.
Skin colour is mainly due to melanin and blood. Interestingly, the number of
melanocytes in skin is the same regardless of the degree of racial pigmentation
it is the rate of pigmentation that differs.
Langerhans cells
Langerhans cells are also dendritic cells, but are found within the body of the epidermis in the Malpighian layer rather than in the basal layer. They derive from the
reticuloendothelial system and have the function of picking up foreign material
and presenting it to lymphocytes in the early stages of a delayed hypersensitivity
reaction. They are reduced in number after exposure to solar UVR, accounting for
the depressed delayed hypersensitivity reaction in chronically sun-exposed skin.
THE DERMIS
The tissues of the dermis beneath the epidermis are important in giving mechanical
protection to the underlying body parts and in binding together all the supercial
structures. It is composed primarily of tough, brous collagen and a network of
bres of elastic tissue, as well as containing the vascular channels and nerve bres
of skin (Fig. 1.10). There are about 20 different types of collagen, but the adult
dermis is made mainly of types I and III, whereas type IV is a major constituent
of the basal lamina of the dermo-epidermal junction. Between the bres of collagen
is a matrix composed mainly of proteoglycan in which are scattered the broblasts that synthesize all the dermal components. Collagen bundles are composed of
6
Collagen fibres
Tropocollagen ~240 nm
Collagen fibre or fibril
Fibroblast
Bundle of collagen
fibres in cross section
Diameter of individual
fibres varies from
20 to 120 nm.
64 nm Periodicity in
long section of fibre
Elastic tissue has two
components:
Microfibrils
Amorphous substance
Elastic fibres
The ratio of
fibrils to
amorphous
substance
varies. High
in papillary
and low in
reticular dermis.
The amorphous substance consists

of molecules of elastin cross linked
via desmosine or isodesmosine.
The microfibrils are biochemically
distinct from elastin and probably
are one of a family of glycoproteins.
(b)
(a)
Figure 1.10 (a) Diagram to show components of the dermis. (b) Photomicrograph to show dermal structure.
Stratum
corneum
Epidermis
Papillary capillary
Dermis
Subcutaneous
fat
Figure 1.11 Diagram to show the

arrangement of the dermal vasculature.
polypeptide chains arranged in a triple helix format in which hydroxyproline

forms an important constituent amino acid.
The dermal vasculature
There are no blood vessels in the epidermis and the necessary oxygen and nutrients
diffuse from the capillaries in the dermal papillae. These capillaries arise from horizontally arranged plexuses in the dermis (Fig. 1.11).
Nerve structures
Recently, very ne nerve bres have been identied in the epidermis, but most of
the bres run alongside the blood vessels in the dermal papillae and deeper in the
7
Figure 1.12
Photomicrographs to
show (a) Paccinian
corpuscle and
(b) Meissner corpuscle
specialized neural
receptors (H & E, 150).
(a)
(b)
dermis. There are several types of specialized sensory receptor in the upper dermis
that detect particular sensations (Fig. 1.12).
THE ADNEXAL STRUCTURES

The skin possesses specialized epidermal structures that can be regarded as
invaginations of the surface that are embedded in the dermis. These are the hair
follicles and the eccrine and apocrine sweat glands.
Hair follicles
Hair follicles are arranged all over the skin surface apart from the palms and soles,
the genital mucosa and the vermilion of the lips. Hair growth is asynchronous in
humans but synchronous in many lower mammals. The different phases of our
asynchronous hair growth occur independently in individual follicles but are
timed to occur together in synchronous hair growth, accounting for the phenomenon of moulting in small, furry mammals. The phase of the hair growth is
known as anagen and is the longest phase of the hair cycle. Following anagen, a
short stage of defervescence is reached known as catagen. This is followed by a
resting phase known as telogen, which is again followed by anagen somewhat later
(Fig. 1.13).
The hair shaft grows from highly active, modied epidermal tissue known as
the hair matrix. The shaft traverses the hair follicle canal, which is made up of a
series of investing epidermal sheaths, the most prominent of which is the external
root sheath (Fig. 1.14). The whole follicular structure is nourished by a small
indenting cellular and vascular connective tissue papilla, which pokes into the
base of the matrix. The sebaceous gland secretes into the hair canal a lipid-rich
substance known as sebum, whose function is to lubricate the hair (Fig. 1.15).
Sebum contains triglycerides, cholesterol esters, wax esters and squalene. Hair
8
Anagen
Catagen
Telogen
Remnant of i
root sheath
Inner root
sheath
Sebaceo
duct
Outer root
sheath
Outer root
sheath
ub
Inner root
sheath
Early anagen
Club
Sebaceous
gland
Telogen
lub hair
b
agen hair
Dermal papilla
Basal lamina
Dermal papilla
Dermal papilla
Dermal papilla
Figure 1.13 Diagram to show hair cycle.
Hair shaft in hair

follicle canal
Epidermis
Sebaceous gland
Hair matrix
(a)
Hair papilla
Figure 1.14 (a) Diagram to show general arrangements

of a hair follicle. (b) Photomicrograph to show a hair
follicle with central hair shaft arising from matrix and
bulbous hair papilla indenting the matrix. Note also the
complex arrangement of the epithelial layers of the hair
canal.
(b)
growth and sebum secretion are mainly under the control of androgens, although
other physiological variables may also inuence these functions.
The eccrine sweat glands are an extremely important part of the bodys
homeothermic mechanism in that the sweat secretion evaporates from the skin
surface to produce a cooling effect. Apart from heat, eccrine sweat secretion may
also be stimulated by emotional factors and by fear and anxiety. Certain body
sites, such as the palms, soles, forehead, axillae and inguinal regions, secrete sweat
selectively during emotional stimulation.
9
Figure 1.15 Photomicrograph to show

sebaceous gland. The empty appearance
of the cells is due to the lipid secretion
being washed out in the histological
preparation (H & E, 90).
(a)
Figure 1.16 (a) Photomicrograph to show tubular

structures of a sweat gland
deep in the dermis (H & E,
150). (b) Photomicrograph
to show a sweat duct
spiralling through the
epidermis and stratum
corneum of the palm
(H & E, 45).
(b)
10
Summary
The eccrine sweat glands consist of a coiled secretory portion deep in the dermis
next to the subcutaneous fat and a long, straight, tubular duct whose nal portion is coiled and penetrates the epidermis to drain at the sweat pore on the surface (Fig. 1.16). The gland and its duct are lined by a single layer of secretory cells
and surrounded by myoepithelial cells.
The apocrine sweat glands drain directly into hair follicles in the axillae and
groins. They are larger than eccrine sweat glands and the secretum is completely
different, being semi-solid and containing odiferous materials that are thought to
have the function of sexual attraction.
Summary
Skin diseases account for about 15 per cent of a
general practitioners workload.
Acne, eczema, psoriasis, warts and skin tumours
are amongst the commonest of all human
disorders.
Skin is the protective interface between the
potentially injurious external environment and the
vulnerable organs and tissues of the body.
The keratinocytes in the epidermis mature into the
attened corneocytes of the stratum corneum. The
stratum corneum prevents water loss, penetration
by substances in contact with the skin and invasion
by micro-organisms.
Keratinocytes are constantly dividing in the basal
layer of the epidermis and corneocytes are shed at
the surface.
Melanocytes are dendritic, pigment-producing cells
in the basal layer of the epidermis.
Langerhans cells are dendritic, bone marrow-derived

cells that seize and process foreign substances
which manage to penetrate the skin and then
present them as antigen to lymphocytes in the rst
stage of delayed hypersensitivity.
The dermis is separated from the epidermis by a
junctional zone consisting of a basal lamina and a
condensation of connective tissue. It contains blood
capillaries that reach up near to the epidermis but
do not penetrate it. Nerve bres ending in sensory
receptors are also found within the dermis.
The bulk of the dermis contains brous collagen,
which gives skin its strength and elasticity, as well
as elastic bres around the collagen bres and a
proteoglycan matrix.
Adnexal structures hair follicles and sweat
glands open at the skin surface but reside in the
dermis.
11
C H A P T E R
Signs and symptoms

of skin disease
12
14
15
Oedema, fluid-filled cavities and ulcers
17
Secondary changes
19
20
Summary
23
Skin disorders may be generalized, localized to one or several sites of abnormality

known as lesions, or eruptive, in which case many lesions appear spottily over
the skin. Note that skin that appears normal to the naked eye may have structural
abnormalities when inspected microscopically and may also demonstrate functional abnormalities. For example the skin around a psoriatic plaque shows slight
epidermal thickening and minor inflammatory changes; similarly, there are alterations in blood flow in the normal-appearing skin near eczematous skin.
Any widespread abnormality of the skin may also affect the scalp, the mucosae
of the mouth, nose, eyes and genitalia, and the nail-forming tissues and it is important to inspect these sites whenever possible during examination of the skin.

The colour of normal skin is dependent on melanin pigment production (see
page 5) and the blood supply. Other factors may also influence it, including the optical qualities of the stratum corneum and the presence of other pigments in the skin.
One of the most common accompaniments of skin disease is redness or erythema.
ERYTHEMA
The degree of erythema depends on the degree of oxygenation of the blood, its rate
of flow and the site, number and size of the skins blood vessels. Different disorders
12
Figure 2.1 Plaques of psoriasis with typical red colour.

Figure 2.2 Reddened areas on the face
in dermatomyositis, showing typical
heliotrope discoloration.
tend to be associated with particular shades of red. Psoriatic plaques, for example,
tend to be dark red in colour rather than pink, bright red or bluish red (Fig. 2.1).
Other diseases associated with specific colours include lichen planus and dermatomyositis. Lichen planus has a well-known mauve hue, which is often helpful in
reaching a diagnosis. Dermatomyositis characteristically has the colour of the heliotrope flower associated with the periocular swelling that frequently occurs in this
disease (Fig. 2.2).
Measurement of the degree of erythema may be helpful in assessing the effects
of treatment on an erythematous skin disease. There are now two types of device
that can be used to do this, one is based on the comparator principle and the other
uses reflectance spectroscopy. Both employ complex electronics, are available commercially and are easy to use.
BROWN-BLACK PIGMENTATION
The degree of brown-black pigmentation depends on the activity of the pigmentproducing cells the melanocytes not on the number of cells. It also depends on
the size of the granules and the distribution of the pigment particles within the
epidermal cells. Shedding of the pigment from keratinocytes into the dermis is
known as pigmentary incontinence and causes a kind of tattooing, in which the
dusky pigment produced hangs on for many weeks or months.
Brown pigmentation is also caused by a breakdown product of blood
haemosiderin when this has leaked into the tissues (Fig. 2.3). It is very difficult to
tell this apart from melanin pigment, both clinically and histologically, but special
stains can help.
A brown-black discoloration of the skin over cartilaginous structures (ears and
nose) and, to a lesser extent, at other sites is seen in alcaptonuria, and is due to the
Figure 2.3 Lower legs of a

patient with chronic venous
hypertension and brown
pigmentation due to
haemosiderin deposits.
13
Signs and symptoms of skin disease
deposition of homogentisic acid. A dark brown pigmentation of acne scars or

of areas on the limbs is sometimes observed as an uncommon side effect of the
tetracycline-type drug minocycline.
Generalized darkening of the skin, more pronounced in the flexures, is observed
in Addisons disease and seems to be due to increased secretion of melanocytestimulating hormone and the consequent activation of the melanocytes to produce
more pigment. Nelsons syndrome following adrenalectomy is another cause of
generalized pigmentation that is also due to the action of melanocyte-stimulating
hormone. Darkening of the palmar creases and mucosae may be seen in both these
endocrine disorders.
Disorders of pigmentation are also discussed in Chapter 17.

The sensation experienced by touching or stroking normal skin is due in part
to the normal skin surface markings which vary to some extent in different areas of
the body (Figs 2.4 and 2.5). It is also dependent on the presence of hair, sweat and
sebum at the skin surface and to the overall mechanical properties of the skin
at that site. Horn cells are constantly being shed from the skin surface (desquamation) at a rate that approximates to the rate at which the epidermal cells are being
produced. The replacement time (turnover time) of the normal stratum corneum
is approximately 14 days, but varies at different body sites and lengthens in old
age. Normally, horn cells are shed singly, and the process is imperceptible. When
the process of keratinization is disturbed, the horn cells tend to separate in clumps
or scales rather than as single cells. Sometimes, the process is so disturbed that
shedding of any type is impossible and the horny layer builds up into a thickened,
horny patch of hyperkeratosis (Fig. 2.6). When the skin surface is scaly and roughened, it looks dry, and scaling skin disorders are sometimes known colloquially
Figure 2.4 Skin surface of the forearm showing typical

rhomboidal pattern.
Figure 2.5 Skin surface of the beard area in a man

with accentuation of the follicular orifices.
14
Figure 2.6 Plantar

hyperkeratosis in a patient
with a congenital disorder of
keratinization.
as dry skin disorders. Water placed on scaling skin makes the surface temporarily
less scaly, but the scaling is not due to water deficiency.
As mentioned above, scaling is due to disturbances in keratinization, which
may be primary or secondary. In primary disorders of keratinization, a metabolic
abnormality prevents full and complete differentiation of the stratum corneum,
ending in the release of intact single keratinocytes. These disorders are generally
congenital in origin the ichthyoses being the best examples.
Scaling is also seen when keratinization is affected secondary to some other
pathological process affecting the epidermis. For example, the scaling seen in psoriasis and eczema is due to the inflammation that affects the epidermis in these
disorders. In psoriasis, and probably in some patients with chronic eczema, epidermal cell production is greatly increased and the rapid movement of the epidermal
cells upwards results in immature cells within the stratum corneum.
There are no simple ways to quantify scaling, although there are established
methods for assessing skin surface contour, in which the contour of skin surface
replicas is tracked with a very sensitive stylus and recorded electronically. Skin
surface contour may also be recorded optically by measuring the reflection of light
from the skin surface.

When a localized lesion no more than discolours the skin surface, it is known as a
macule. If the abnormal area is raised up above the skin surface, it is said to be a
plaque. The mild fungal disorder known as pityriasis versicolor (see page 37)
causes macules over the chest and back (Fig. 2.7), but the lesions of psoriasis
15
Figure 2.7 Pityriasis versicolor, showing many brownish

pink macules on the chest.
Figure 2.8 Annular lesion of ringworm.
Figure 2.9 Annular lesion of granuloma

annulare.
Figure 2.10 Lesion of erythema multiforme showing

annular lesion.
(see page 100) are thickened and easily palpable and are called plaques. Sometimes,
lesions are very considerably proud of the skin and are known as nodules or
tumours. If the tumours are connected with the skin surface by a stalk, they are
said to be pedunculated. Nodules and pedunculated tumours are present in the
congenital condition called neurofibromatosis (Von Recklinghausens disease).
The edge of lesions can give some diagnostic help: well-defined edges are especially characteristic of psoriasis and ringworm. Characteristically, it is difficult to
discern where the abnormality ends in the eczematous disorders.
The shape of skin lesions can also help in diagnosis. Some skin disorders start off
as macular but clear in the centre, making ring-like or annular lesions. Ringworm,
granuloma annulare (see page 265) and erythema multiforme (see page 75) are
16
Figure 2.11 Typical lesions of lichen planus on the

front of the wrist. The individual papules have a roughly
polygonal outline and are mauvish in colour.
Figure 2.12 Dermographic weals.
three conditions in which the developed lesions tend to be annular (Figs 2.82.10).
Some skin disorders often produce oval lesions, pityriasis rosea being the best
example of this tendency. Occasionally, lesions assume bizarre patterns on the skin
surface that almost seem to be representing a particular pattern or symbol. This is
termed figurate, and many disorders, including psoriasis, may produce such lesions.
For the most part, skin lesions are not usually angular and do not form squares or
triangles. However, one condition, lichen planus (see page 144), does produce small
lesions that seem to have a roughly polygonal outline (Fig. 2.11).
In some instances, lesions such as plaques or tumours infiltrate into the substance of the skin and, in the case of such malignant lesions as basal cell carcinoma, squamous cell carcinoma or malignant melanoma, it is important to
recognize the presence of deep extensions of the lesion in order to plan treatment.
Clinically, it is possible for experienced observers to form some impression of the
degree of infiltration present by palpation, but this should be validated by histological support before any major surgical decision is made. There is some hope
that non-invasive assessment techniques such as ultrasound will be better able to
guide the surgeon than clinical examination alone.

When a tissue contains excess water both within and between its constituent cells,
it is said to be affected by oedema. Oedema fluid may collect because of inflammation, when it is protein rich and known as an exudate, or as a result of haemodynamic abnormalities, when it is known as a transudate. Oedema is a common
feature of inflammatory skin disorders, being seen in acute allergic contact dermatitis. Oedema also occurs in urticaria and dermographism (see page 71) in which
localized areas of pink, swollen skin (known as weals) occur, lasting for several
hours (Fig. 2.12).
17
Figure 2.13 Vesicles in

eczema from patch test.
(a)
Figure 2.14 (a) Bullous lesion in senile

pemphigoid. (b) Numerous bullae in the
groin in a patient with pemphigus.
(b)
In eczema, oedema fluid collects within tiny cavities less than 1 mm in diameter
within the epidermis, known as vesicles (Fig. 2.13). Larger fluid-filled cavities are
called bullae (blisters). These may form due to fluid collecting beneath the epidermis (subepidermal), in which case their walls tend to be tough and the captured
blister fluid may be blood stained, or they may form by separation or breakdown
of epidermal cells (intraepidermal), when the walls tend to be thin, flaccid and
fragile. Subepidermal bullae form in bullous pemphigoid, dermatitis herpetiformis
and erythema multiforme. Intraepidermal bullae form in the different types of
pemphigus (see page 91) and herpes virus infections (see Figs 2.142.18).
18
Secondary changes
Figure 2.15 Vesicles in dermatitis herpetiformis.
Figure 2.16 Bullae of the palm in erythema multiforme.
Figure 2.17 Flaccid bullae in pemphigus.
Figure 2.18 Vesicles in herpes zoster.
An erosion is any breach of the epidermis. The term ulcer is used to denote a
broad, deep erosion that persists. Erosions may be covered by serous exudates or
crust; ulcers tend not to be covered.
Secondary changes
Secondary changes include:
impetiginization due to a bacterial infection resulting in exudation and

golden-yellow crusting (Fig. 2.19)
lichenification the result of constant rubbing and scratching causing thickening, with exaggeration of the skin surface markings (Fig. 2.20)
prurigo papules also the result of scratching, but, instead of lichenification,
variably sized inflamed papules and even quite large nodules appear (Fig. 2.21).
19
Figure 2.20 Lichenification showing

scaling and accentuation of skin markings.
Figure 2.21 Excoriated papules in

prurigo.
Figure 2.19 Impetigo

contagiosa showing
exudation and golden-yellow
crusting.
Case 1
Jack has had severe generalized eczema since the age of 3. It is extremely itchy,
and he scratches it vigorously, causing scratch marks or excoriations to appear.
In some areas where he scratches and rubs persistently, the skin has become
thickened and hypertrophied, with exaggeration of the skin surface markings
a change known as lichenification. In areas that are eczema free, there is
xeroderma or drying of the skin with some fine scaling. In places where the
eczema is active, the skin is red from the increased blood supply and swollen
because of the oedema.

Skin disease causes pruritus (itching), pain, soreness and discomfort, difficulty
with movements of the hands and fingers, and cosmetic disability.
PRURITUS
Itching is the classic symptom of skin disorders, but it may occur in the apparent
absence of skin disease. Any skin abnormality can give rise to irritation, but some,
such as scabies, seem particularly able to cause severe pruritus. Most scabies
patients complain that their symptom of itch is much worse at night when they
get warm, but this is probably not specific to this disorder. Itching in atopic dermatitis, senile pruritus and senile xerosis is made worse by repeated bathing and
vigorous towelling afterwards, as well as by central heating and air conditioning
with low relative humidity. If pruritus is made worse by aspirin or food additives
such as tartrazine, sodium benzoate or the cinnamates, it is quite likely that
20
urticaria is to blame. Persistent severe pruritus can be the most disabling and distressing symptom, which is quite difficult to relieve. Scratching provides partial
and transient relief from the symptom and it is fruitless to request that the patient
stop scratching. Scratching itself causes damage to the skin surface, which is visible as scratch marks (excoriations). In some patients, the repeated scratching and
rubbing cause lichenification and in others prurigo papules occur. Occasionally,
the scratch marks become infected. Uncommonly, the underlying disorder occurs
at the site of the injury from the scratch. This phenomenon is found in patients
with psoriasis and lichen planus and is known as the isomorphic response or the
Koebner phenomenon.
PAINFUL SKIN DISORDERS

Most skin disorders do not give rise to pain. The notable exception to this is shingles (herpes zoster), which may cause pain and distorted sensations in the nerve
root involved (see page 52). The pain may be present before the skin lesions
appear, while they are there and, occasionally, afterwards. Pain and tenderness are
characteristic of acutely inflamed lesions such as boils, acne cysts, cellulitis and
erythema nodosum (see page 77). Most skin tumours are not painful, at least until
they enlarge and infiltrate nerves. However, there are some uncommon benign
tumours that cause pain, including the benign vascular tumour known as the glomus tumour and the benign tumour of plain muscle known as the leiomyoma.
Chronic ulcers are often sore and cause a variety of other discomforts, but
they are not often the cause of severe pain. When they do give rise to severe pain,
ischaemia is usually the cause. Painful fissures in the palms and soles develop in
patches of eczema and psoriasis due to the inelastic, abnormal, horny layer in
these conditions.
DISABILITIES FROM SKIN DISEASE

Patients with skin disease may experience a surprising degree of disability. A very
major cause of disability is the abnormal appearance of the affected skin. For reasons
that are not altogether clear, there is a primitive fear of diseased skin, which even
amounts to feelings of disgust and revulsion. The idea of touching skin that is scaling or exudative seems inherently distasteful and it is something that one tries to
avoid. These attitudes appear universal and inherent, and it is difficult to prevent
them. It is little use pointing out that there is no rational basis for them, and all that
can be hoped for is that a mixture of comprehension, compassion and common
sense eventually supplants the primitive revulsion felt by all. It has been suggested
that the origins of the inherent fear described above are the contagious nature of leprosy and the infestations of scabies and lice. Indeed, the problem is sometimes
referred to as the leper complex. Regardless of the origins, it is only too abundantly
evident that individuals with obvious skin disease do not do well where the choice
of others is concerned. They suffer more unemployment overall, but in addition
21
Figure 2.22 Erythema and papules of the

cheek in rosacea.
Figure 2.23 Plaques of erythema,

scaling and hyperkeratosis in a man with
discoid lupus erythematosus.
find great difficulty in obtaining positions that require any kind of interpersonal
relationships.
Young patients with acne have particular problems because the disease is only
too visible, as it usually affects the face. Psoriasis quite often affects the hands, nails
and scalp margin, also causing difficulty for those whose occupations put them
into contact with the public.
Numerous other skin disorders put the affected individual at an economic and
social disadvantage. Vascular birthmarks and large neurofibromata are disfiguring
and tend to isolate the bearers. Chronic inflammatory facial disorders such as
rosacea and discoid lupus erythematosus also cause problems (Figs 2.22 and 2.23).
To summarize this point, individuals with visibly disordered skin are disabled
because of societys inherent avoidance reaction. One other aspect of this same
problem is the sufferers own perception of the impact they are making on all with
whom they come in contact. In most subjects who have persistent, unsightly skin
problems, the affected individuals become depressed and isolated. It is especially
damaging for those in their late teens and twenties who are desperately trying to
make relationships. Self-confidence is, in any case, not at a high point at this time in
their emotional development and a disfiguring skin disorder lowers their selfesteem incalculably. Many youngsters with acne and psoriasis find it difficult to conquer their embarrassment sufficiently to have girlfriends or boyfriends and that
aspect of their development may become stunted. It was once thought that many
skin disorders were caused by neurotic traits, stress and personality disorders. It is
22
Summary
Figure 2.24 Skin fissures in atopic dermatitis.
now increasingly appreciated that skin disorders often cause depression, anxiety and
stress, so that the wheel has turned full circle.
Skin disease can be enormously disabling when it affects the palms or soles.
Although the areas only occupy some 12 per cent of the bodys skin surface, disease of these sites may prevent walking and use of the hands for anything but
simple tasks, i.e. they are virtually completely disabled. Psoriasis and eczema are
the usual causes of this form of disablement because of the painful fissures that
tend to develop (Fig. 2.24). Patients with a severe atopic dermatitis may develop
similar painful fissures around the popliteal and antecubital fossae, so that limb
movements become extremely painful (Fig. 2.25). Those with severe congenital
disorders of keratinization are often severely troubled by this disordered mobility.
From what has been said so far, it will be appreciated that, contrary to popular
belief, patients with skin disorders are often appreciably disabled. They are
disabled on account of societys and their own reaction to the disease and because
of the physical limitations that the skin disease puts on them.
Skin disease infrequently kills, but often produces unhappiness, usually loss of
work and social deprivation as well as considerable physical discomfort.
Summary
Skin disorders may be generalized or localized to
lesions.
Normal-appearing skin may show structural or
functional abnormalities.
Skin colour is mainly determined by melanin
pigmentation and blood content, its oxygenation
and distribution. Particular shades of red may
indicate particular diseases, e.g. violaceous lichen
planus.
Figure 2.25 Painful

fissures in popliteal fossae
in atopic dermatitis.
The degree of skin pigment depends on the rate of

melanin production and the size of the melanin
granules not the number of melanocytes, which is
constant. Pigment shed into the dermis causes
persistent darkening.
The quality of the skin surface depends on hair,
sebum and sweat secretion, and desquamation.
Scales are aggregates of corneocytes and result
from the failure of the usual loss of cohesion
23
between corneocytes regardless of the underlying

abnormality.
Erythema, pigmentation and scaling can all be
measured objectively.
Macules are flat; plaques are flat raised patches.
Papules, nodules and tumours are progressively
larger, localized, raised lesions. Annular lesions
occur, for example, in ringworm, erythema
multiforme and granuloma annulare.
Oedema is often a feature of inflammatory disorders
of skin, including acute eczema and urticaria.
Subepidermal blisters (bullae) occur in erythema
multiforme, bullous pemphigoid, porphyria cutanea
tarda, epidermolysis bullosa and dermatitis
herpetiformis.
Intraepidermal blisters (bullae if large, vesicles
if small) occur in pemphigus of various types,
herpes simplex and zoster and sometimes in

eczema.
Pruritus causes scratching and thus scratch marks
(excoriations) and skin hypertrophy or lichenification
if persistent. Prurigo papules and impetiginization
also result from scratching.
Itching is particularly a problem in atopic
dermatitis, scabies, dermatitis herpetiformis and
urticaria.
Pain in skin disorder is a feature of herpes zoster
(shingles), some uncommon tumours and fissures
in the skin in chronic eczema.
Disability in skin disorder results from societal
rejection and the patients self-imposed isolation
because of fear of the peer response. This results
in emotional deprivation, occupational disadvantage
and economic loss.
24
C H A P T E R
Skin damage from

environmental hazards
26
27
29
Summary
35
As already mentioned, a major function of skin is its ability to protect the body from
the potentially injurious environment. All parts of the skin contribute to its role in
protection. The stratum corneum is a remarkably efcient barrier, protecting against
water loss to the environment and against the entry of toxic substances that the skin
may encounter. This same, thin structure also helps protect against solar ultraviolet
radiation (UVR), thermal injury and, to some extent, mechanical damage.
The vasculature is vital to the maintenance of a constant body temperature.
Vasodilatation and vasoconstriction allow loss and conservation of body heat,
respectively. The sweat glands, the hair and the subcutaneous fat are other parts
of the skin that assist in thermal homeostasis. Evaporation of sweat assists loss of
body heat, and the subcutaneous fat and hair help conserve heat because of their
insulating functions.
Melanin produced by melanocytes in the basal layer of the epidermis is
donated to the epidermal keratinocytes, which become corneocytes, and it is in
these that melanin absorbs solar UVR, providing essential protection to the skin
against damage from the suns rays. UVR stimulates melanin production, leading
to the well-known golden brown suntan and further protection.
We are subjected to a constant barrage of mechanical stimuli, which vary in
intensity, direction, area to which they are delivered and rate of delivery. The dermis contains a network of oriented, tough, collagenous bres, in the interstices of
which there is a viscid proteoglycan ground substance as well as elastic bres and
broblasts. Most of the mechanical response to physical stimuli is due to dermal
connective tissue. Overall, the mechanical properties can be described as viscoelastic. This means that skin extends in response to a linear force and will tend to
regain its original length after release of the force (elastic). It also ows and creeps
with some mechanical stimuli (viscous). Skin is also said to be anisotropic, as its
25
Skin damage from environmental hazards
mechanical properties vary according to the orientation of the body axis in which
the mechanical stimulus is delivered. The anisotropy results from the orientation
of the collagen bres, which vary according to site. Different resting tensions result
from the differing orientations and account for the development of broad and ugly
scars if incisions are made across the main orientation of the collagen bres rather
than parallel to it. Langers lines (made by joining the long axes of circular incisions
pulled by the internal forces over the skin surface) were an early attempt at revealing the resting tensions in skin. However, they did not take into account important
additional local considerations specic to each anatomical region.
The responses to mechanical stimuli vary according to the rate of delivery of the
stimulus, i.e. they are time dependent. They are also dependent on the stress history
of the anatomical part recent stress history being more important than distant.

Skin encounters substances with widely ranging toxicities. It must be remembered
that many agents used in treatment, such as corticosteroids and salicylic acid, are
systemically absorbed when placed on the skin and may cause systemic toxicity.
Detergents, alkaline soaps and lubricating oils are some of the substances that
can damage the skin after repeated contact. They damage the horny layer by
removing complex lipids and glycoproteins from the intercorneocyte space and
then irritate the epidermis, causing a dermatitis characterized by oedema and the
presence of inammatory cells (Fig. 3.1). Although everyone may be injured by
irritating substances, susceptibility varies. More heavily pigmented individuals are
more resistant, but fair-skinned, blue-eyed people, and especially red-haired individuals, are particularly sensitive. Celtic people are especially vulnerable, though
the basis for their vulnerability is not clear. The sensitivity to chemical irritants
parallels the sensitivity to UVR (Fig. 3.2).
Figure 3.1 Photomicrograph showing inammation, with

inammatory cells in the dermis and epidermis and
oedema (spongiosis) of the epidermis.
Figure 3.2 Severe irritant dermatitis caused by sodium

lauryl sulphate, showing crusting.
26
LESS COMMON TOXICITIES

Corrosive and blistering injury
Agents that cause blistering are known as vesicants. Blister beetles release vesicants
(including cantharidin) when crushed on the skin. Colloquially known as Spanish
y, the substance, unjustiably, had the reputation of being an aphrodisiac.
Chemical warfare agents include vesicants known as the mustards, which crosslink DNA, preventing cell division, but also cause severe blistering and erosion on
contact with the skin.
Acneiform response
Some materials particularly irritate the hair follicles and stimulate the production
of sticky horn, causing comedos and an acneiform folliculitis (Fig. 3.3). Cocoa
butter, thick, oily materials including parafn waxes and substances such as isopropyl myristate are notorious for doing this in susceptible individuals. Cosmetics
were at one time often to blame, but now rarely have this effect because of rigorous safety testing. Lubricating and cutting oils may cause oil folliculitis or oil
acne in machine workers at skin sites that come into contact with the oil.
Figure 3.3 Acne lesions

induced by cosmetic
preparations.
Pigmentary disorders from toxic substances
Some materials can injure melanocytes, causing depigmented patches that may
closely resemble vitiligo (see page 297). Substances used in the rubber industry
notably the additive paratertiary butyl phenol are notorious for causing such a
problem. Depigmentation may occur as a temporary phenomenon after irritant
dermatitis or other inammatory dermatoses. Hyperpigmentation can also follow
inammatory skin disease. This can be persistent as it results from the release of
melanin particles from injured keratinocytes, which are then engulfed by macrophages, resulting in a tattoo.

The sun emits a continuous band of energy over a wide range of wavelengths, but
it is only the UVR (250400 nm) that is of major importance as far as skin is concerned (Fig. 3.4). Three segments of UVR are recognized: UVA (320400 nm), or
long-wave UVR; UVB (280320 nm), or medium-wave UVR; and UVC
(250280 nm), or short-wave UVR. UVC is mostly ltered out by the ozone layer
and would only become biologically important if the ozone layer became seriously
depleted.
UVB especially around 290 nm is mainly responsible for sunburn, suntan and
skin cancer, although other wavelengths contribute to the pathogenesis of these
conditions. UVB only penetrates as far as the basal layer of the epidermis, but causes
the death of scattered keratinocytes (sunburn cells) and damages others so that they
release cytokines and mediators. These produce oedema, vasodilatation and a
27
VISIBLE LIGHT
Figure 3.4 Solar

spectrum to show visible
light and ultraviolet
radiation (UVR). The UVR
is divided into three
portions: (a) long-wave
UVR, (b) medium-wave
UVR, and (c) short-wave
UVR.
700
600
500
ULTRAVIOLET RADIATION
400
320 280
185
Wave length (nm)
subepidermal inammatory cell inltrate. Some 2 days after UVR injury, there is an
increase in the rate of melanin synthesis. It is probably not possible to stimulate a
tan without sustaining UVR-induced epidermal damage. Sunburn is easily recognized by the redness and, when severe, swelling and blistering as well. For some
unexplained reason, it is quite sharply restricted to the area of skin exposed. The
affected area is very sore and, if blistered and extensive, makes the individual feel
unwell and even require in-patient management as for a thermal burn.
An individuals sensitivity to solar UVR depends mostly on the degree of skin
pigmentation, but also to some extent on inherent metabolic factors. Sensitivity is
conventionally graded as follows in answer to the question Do you burn or tan in
the sun?
Type I
Type II
Type III
Type IV
Type V
Type VI
Always burns, never tans

Always burns, sometimes tans
Sometimes burns, always tans
Never burns, always tans
Brown-skinned individuals of Asian descent
Black-skinned individuals of African descent
Although UVA is 1000-fold less effective at causing erythema, there is a lot of

it in sunshine and it does penetrate to the dermis. It is thought to play a role in
causing the dermal degeneration known as solar elastosis, which is mainly responsible for the appearance of ageing as well as contributing to the cause of skin cancer. UVA is also the part of the spectrum mainly responsible for photosensitivity
reactions.
Case 2
Mary and Louise are non-identical twins. Mary has blond hair, blue eyes and pale
skin, whereas Louise has brown hair and eyes and slightly darker skin. Mary has
found that she becomes red and sunburnt easily and cannot tan, but Louise can
stay in the sun longer without burning. At the age of 45, Mary noticed that she
had quite a few wrinkles in the crows feet areas and around the mouth, but
Louise still looked quite young.
28

The wrinkling and other changes in exposed skin commonly believed to be due to
ageing are, in fact, mainly due to chronic damage from solar UVR. The changes
are more in evidence in those with outdoor occupations, such as farmers, builders
or sailors. They are worse in fair-skinned, blue-eyed individuals who are easily
sunburnt. However, with the advent of package holidays and cheap air travel, glorification of the great outdoors and the obsession with obtaining a suntan, excess
sun exposure is commonplace, resulting in unnecessary photodamage. Persisting
sun exposure results in both epidermal and dermal damage.
EPIDERMAL DAMAGE
Minor degrees of epidermal abnormality, with variation in cell and nuclear size,
shape, staining and orientation, are known as dysplasia (or photodysplasia). They
are common and, although they are not detectable clinically, they may lead on to
pre-cancerous solar keratoses or Bowens disease, frankly invasive squamous or
basal cell carcinoma (see Chapter 13) and life-threatening malignant melanoma
(see Chapter 13).
DERMAL DAMAGE
Sun-damaged dermal connective tissue loses its brous quality and assumes a
homogenous, blob-like appearance in some sites and a chopped-up, short, stubby
bre appearance in others. When these occur together, they give a spaghetti and
meatball appearance. The degenerative change is termed solar elastosis as it stains
just like elastic tissue. Solar elastosis starts subepidermally, although separated
from the epidermis by a thin layer of normal dermis the grenz zone. With
increasing exposure, elastotic tissue extends deeper and deeper into the dermis.
Solar elastosis imparts a sallow, yellowish tint to affected skin and the altered
mechanical properties of the abnormal tissue are responsible for many of the
wrinkles and lines around the mouth and eyes on sun-damaged skin (Fig. 3.5).
Large telangiectatic blood vessels in the degenerate dermis account for the telangiectasia seen clinically (Fig. 3.6).
Topical retinoids (tretinoin, isotretinoin and tazarotene) used over several
months improve the appearance of photodamaged skin by stimulating the synthesis of new dermal connective tissue.
PREVENTION OF PHOTODAMAGE
Complete avoidance of sun exposure is very difcult to achieve and it is better to
aim at reducing the UVR dose as much as possible by:
avoiding exposure between 11.30 am and 2.30 pm

seeking shade
29
Figure 3.5 Clinical signs of solar

elastotic degenerative change, showing
marked wrinkling around the mouth and
eyes.
Figure 3.6 Solar elastotic degenerative

change of the cheek, showing marked
telangiectasia.
using opaque protective clothing, including broad-brimmed hats, trousers

and long-sleeved shirts
using sunscreens.
Sunscreens are creams or lotions that absorb and lter out or reect off the
damaging UVR. Older sunscreens contained substances such as the esters of
paraaminosalicylic acid, benzoic acid, the homosalicylates, the benzophenones
and the cinnamates, designed primarily to lter out the sunburning 290-nm UVB
segment, although some also gave a little protection in the UVA range. Newer
sunscreen constituents give protection against UVA as well and may be helpful in
protecting against chronic photodamage and skin cancer.
Sunscreen efcacy is usually quoted as a sun protection factor (SPF). The SPF
is the ratio of the minimal time of exposure to produce redness of the skin (in
minutes) with sunscreen protection compared to the minimal exposure time to
produce redness without sunscreen protection. For example, if it takes 15 minutes exposure to a standard UVR source to develop redness and only 1 minute to
develop redness without the sunscreen, the SPF of that sunscreen is 15. The test
has been carefully standardized so that one can place some condence in the SPF
as an indication of the protection against UVB.
It is more difcult to measure and express protection against UVA. In practice,
the protection against UVA provided by sunscreens is often expressed as a ratio of
30
the protection against UVB to that offered to UVA in the star system, in which four
stars express the best ratio. There are two methods employed. One is the pigmentdarkening method, in which the time to the production of a transient darkening
of the skin is measured. The other method is an in vitro spectroscopic method.
Other important points concerning sun exposure include:
UVR is readily reected from whitish surfaces such as sand, snow and white
walls, and this increases the dose of UVR sustained.
A signicant amount of UVR diffuses through cloudy skies, and it is possible
to be burnt even on dull days.
The nearer the equator, the more direct the UVR and the easier it is to burn.
The higher the altitude of exposure, the greater the UVR exposure.
Lighter-skinned subjects are more at risk, i.e. ginger-haired or axen-haired,
blue-eyed, pink-skinned individuals who never tan and always burn (type I
subjects and, to a lesser extent, type II individuals). A Celtic ancestry, even in
comparatively darker-complexioned subjects, usually signies a marked sensitivity to solar UVR.
DERMATOSES PRECIPITATED AND/OR CAUSED BY

SOLAR EXPOSURE
Photosensitivity reactions (see Table 3.1)
Skin can become sensitized to a specic part of the solar spectrum by chemical
agents that reach it either via the systemic route or after contacting the skin topically.
The molecule damages tissues after absorbing the UVR at a particular wavelength
Table 3.1 Skin diseases precipitated, caused or aggravated by sunlight
Disorder
Wavelengths responsible
Comment
Porphyrias
400 nm
Mostly blistering or erosive disorders, except for

EPP, which causes erythema or urticarial patches
Polymorphic light
eruption
Mostly the UV part of the spectrum, Papular or eczematous rash on exposed areas
but visible light may be involved
Actinic prurigo
Uncertain
Eczematous rash on exposed areas
Photosensitivities
Mostly the long-wave part of the

UV spectrum
Many drugs and chemicals may cause this
Lupus erythematosus
Varies with patients
Acute attack may be precipitated by exposure
Chronic actinic dermatitis Variable; mostly the long-wave

(persistent light reaction part of the UV spectrum
or actinic reticuloid)
Patients may be acutely sensitive to

light exposure
Eczema/psoriasis
Unknown
Some patients improve, some are aggravated
Rosacea
Unknown
Most are aggravated
EPP erythropoietic protoprophyria; UV ultraviolet.

31
Table 3.2 Examples of common photosensitizing agents

Systemically administered drugs
Tetracyclines
Phenothiazines
Amiodarone
Nalidixic acid
Psoralens
Topically administered drugs
Halogenated salicylanilides
Psoralens
Tars
Figure 3.7 Thickening and inammation of the skin of
the forehead in actinic reticuloid.
and becoming activated. This is known as a phototoxic reaction. On occasions, the

molecule becomes allergenic after exposure to UVR and a photoallergic reaction
develops. Some common photosensitizing agents are given in Table 3.2.
Phytochemical reactions are photosensitivity responses that result from contact
with plants or their products on areas exposed to the sun. The psoralens and coumarins are the most common plant sensitizers. Giant hogweed and meadow grass
contain coumarins, and psoralens are found in some fruits, such as the bergamot.
Chronic actinic dermatitis (persistent light reaction;
actinic reticuloid syndrome)
Patients with this disorder start with severe photoallergic dermatitis and do not
respond to routine light avoidance. When photosensitivities are identied to plant
extracts or to antimicrobials such as trichlorosalicylanilide, avoidance does not
necessarily produce improvement. The skin of a few severely affected individuals
may be markedly thickened (Fig. 3.7) and may be involved on all sites not only
light exposed areas. The condition is then known as actinic reticuloid. Severely
affected patients need to be nursed in a darkened room to ensure complete protection from irradiation. Some improvement with azathioprine (50150 mg daily)
may be expected, but little else helps.
Polymorphic light eruption
This is a common disorder, occurring in young and middle-aged women and

characterized by itchy papules and papulovesicles on exposed sites particularly
the forearms (Fig. 3.8). The rash develops shortly after sun exposure throughout
the spring and summer months. Those affected are found to have a marked sensitivity to long-wave UVR.
Patients improve when they avoid sun exposure and use sunscreens blocking
UVA. Weak topical corticosteroids may help, but some severely affected patients
32
Figure 3.8 Polymorphic light eruption

with erythema affecting the face and the
light-exposed part of the neck and upper
cheek.
may need hydroxychloroquine (200 mg b.d.) or even azathioprine (50 mg b.d.).

Desensitizing patients with photochemotherapy with UVA (see Chapter 21)
sometimes helps.
Hutchinsons summer prurigo
This occurs in girls and young women and looks somewhat like atopic dermatitis.
Conrmatory tests for the photodermatoses
Photopatch tests. Suspected photosensitizers are placed on the skin and irradiated with broad-spectrum UVR. Controls are run with irradiation alone and
with the suspected substances without irradiation. Patches are examined for
signs of eczema up to 72 hours after irradiation.
Photoprovocation tests. These specialized tests are only available at a few centres.
In one group of tests, the wavelength dependency (action spectrum) of the disorder is determined by shining monochromatic radiation (single wavelength)
on the skin using a monochromator.
Sweat rash
The term is quite non-specic and applied by the lay public to any disorder associated with sweating and the hot weather. Dermatoses as diverse as intertrigo and
folliculitis are sometimes known as sweat rashes.
33
A common form of sweat rash is due to blockage of the sweat gland pores or
ducts near the surface with swollen over-hydrated horn. The term miliaria crystallina is applied to the tiny, thin walled vesicles that arise from blockage at the
pore near the surface. In miliaria rubra, red, inamed papules occur due to blockage lower in the duct. In miliaria profunda, the blockage is deep down and large
inammatory swellings develop. The most effective treatment is to cool the patient
with air conditioning and fans. Systemic antibiotics and anti-inammatory agents
may be required.
Dermatoses aggravated by solar exposure
Lupus erythematosus is very often aggravated by sun exposure, and patients with
this disease must not expose themselves to solar UVR. Rosacea is often, and atopic
dermatitis occasionally, made worse by the sun. Psoriasis and acne are mostly
improved by sun exposure, but some patients are, for some reason, made worse.
COLD INJURY
Frostbite is a form of acute tissue necrosis of ngers, toes, nose or ears due to coldinduced ischaemia.
Chilblains
Chilblains are common in the UK but rare elsewhere. They seem to occur in the
damp cold so often experienced in the UK and are also associated with subsequent warming. The lesions occur on the ngers, toes and occasionally elsewhere
as raised, dusky red or mauve swellings and are painful and/or itchy. They particularly affect plump young women, for some reason, as well as the elderly. Keeping
warm is the only effective treatment.
Raynauds phenomenon
Table 3.3 Some common
causes of Raynauds
phenomenon
Systemic sclerosis
Systemic lupus
erythematosus
Use of vibratory tools
Carpal tunnel syndrome
Cervical rib
Atherosclerosis
Polycythaemia rubra vera
In the majority of cases, no
precipitating cause can be found.
This common, curious response of the digital arteries to the cold is observed in
many disorders as well as occurring without any obvious underlying predisposing
condition (Table 3.3).
Classically, the ngers suddenly go a deathly white when exposed to the cold.
After a variable period, they go pink and then develop a bluish discoloration
the whole sequence lasting approximately 30 minutes. The condition is painful
and, during the winter, quite disabling. If severe, it can lead to atrophic changes
with loss of tissue and tapering of the ngers. Paronychial infection is a common
complication.
If no underlying cause can be found or the cause cannot be removed, symptomatic treatment directed towards keeping the hands warm and producing vasodilatation in them is needed. Electrically heated gloves, oral inositol nicotinate,
nifedipine (510 mg t.d.s.) and oxypentifylline (400 mg, two to three times daily)
may help individual patients.
34
Summary
Figure 3.9 Erythema ab igne, showing

a brownish reticular network on the leg.
HEAT INJURY
Chronic heating causes injury to the skin, though this is not well characterized.
Infra red in the solar spectrum may play a role in chronic photodamage, but it is
difcult to determine what that role is. Chronic heat damage to the skin occurs on
the shins and elsewhere at sites habitually warmed by focal sources of heat a
condition known as erythema ab igne. Brownish-red reticulate pigmentation is
the dominant physical sign (Fig. 3.9), but keratoses and even squamous cell carcinoma can also occur at involved sites.
Summary
Damage to the skin may be caused by soaps,
detergents and oils that remove essential
constituents of the stratum corneum, allowing
penetration into and irritation of the epidermis.
Fair-skinned individuals are more susceptible to
injury from irritants.
Some agents, such as cocoa butter, irritate the hair
follicles in particular and cause an acne-like
response (comedogenic substances).
Toxic damage to melanocytes by some substances
causes areas of depigmentation.
Solar UVR includes UVB (280320 nm), which

causes sunburn and, over long periods, skin cancer
as well as the changes known as photoageing
(chronic photodamage). It also contains much UVA
(320400 nm), which is less potent than UVB but
can still damage the skin.
The degree of damage caused by UVR depends on
the dose received and the sensitivity of the
individual, which mostly depends on the degree of
skin pigmentation. Asking whether patients sunburn
and can suntan allows categorization into a skin type.
35
Persistent sun exposure damages the epidermis

and causes pre-cancerous lesions, such as solar
keratoses and Bowens disease, and frankly malignant
lesions, including squamous cell carcinoma, basal cell
carcinoma and malignant melanoma.
Sun exposure also damages the dermis, causing
the production and deposition of an abnormal
elastic tissue. This elastotic degeneration is
responsible for many of the appearances of ageing,
including wrinkling and telangiectasia.
Solar damage can be prevented by avoiding exposure
at times of maximum irradiation and by the use of
sunscreens. The latter should protect against both
UVB and UVA.
UVR also causes certain dermatoses, such as
phototoxic and photoallergic reactions when the

skin has been exposed to certain chemicals. Some
disorders, such as polymorphic light eruptions and
actinic prurigo, are caused by exposure to solar UVR
alone.
Exposure to cold can cause frostbite (a type of
gangrene) or chilblains or provoke vasospasm of the
digital arteries causing Raynauds phenomenon, in
which the ngers go white, pink and blue in
sequence. The condition may occur for no obvious
reason or be the result of an underlying disorder
such as the carpal tunnel syndrome, cervical rib or
systemic lupus erythematosus.
Chronic heating can cause erythema ab igne and
skin cancer.
36
C H A P T E R
Skin
infections
Fungal disease of the skin
37
44
50
Summary
56
The stratum corneum is an excellent barrier to pathogenic micro-organisms, but

is itself sometimes the target of attack. The skin surface and its adnexal structures
harbour a stable microora, which lives in symbiosis with skin and may indeed
be benecial. Gram-positive cocci (Staphylococcus epidermidis), Gram-positive
lipophilic microaerophilic rods (Propionibacterium acnes) and a Gram-positive
yeast-like organism (Pityrosporum ovale or Malassezia furfur) live in the follicular
lumina without normally causing much in the way of harm. However, under
special conditions, e.g. excess sebum secretion, depressed immunity and compromised stratum corneum barrier protection, they can produce disease. Infection of
the skin only occurs when the skin encounters a pathogen that its defences cannot eliminate or control.
Fungal disease of the skin/the supercial

mycoses/infections with ringworm fungi
(dermatophyte infections)
Dermatophyte infections are restricted to the stratum corneum, the hair and the
nails (i.e. horny structures).
PITYRIASIS VERSICOLOR
This disorder is caused by the yeast-like micro-organism Pityrosporum ovale. This
microaerophilic, lipophilic denizen of the normal follicle only occasionally becomes
pathogenic when its growth is encouraged by heightened rates of sebum secretion
or there is depressed immunity.
37
Skin infections
Clinically, pale, scaling macules develop insidiously over the skin of the chest
and back in young adults (Fig. 4.1), although, uncommonly, other sites can be
affected too (Fig. 4.2). Pale areas are left when the condition resolves. Diagnosis
is made by identication microscopically of grape-like clusters of spores and a meshwork of pseudomycelium in skin scrapings made more transparent by soaking the
scales for 20 minutes in 20 per cent potassium hydroxide. A more elegant and permanent preparation can be made using cyanoacrylate adhesive (crazy glue) to remove
a strip of supercial stratum corneum from the skin surface on a glass slide. The
slide is rolled off the skin after 20 seconds and then stained with periodic acidSchiff reagent (Fig. 4.3). This technique is known as skin surface biopsy. The skin
patches often uoresce an apple green in long-wave UVR (Woods light).
Figure 4.1 Brownish pink macules on the

trunk due to infection with Pityriasis
versicolor.
Figure 4.2 Hypopigmented macules on the neck of a

black-skinned subject.
Figure 4.3 Periodic acid-Schiff-positive spores and

pseudomycelium of Pityriasis versicolor in skin surface
biopsy.
38
Treatment
Topical imidazole creams (e.g. miconazole, clotrimazole, econazole) applied once

daily over 6 weeks or use of ketoconazole shampoo to wash the affected areas once
daily for 5 days are usually sufcient. Older remedies such as 20 per cent sodium
thiosulphate solution and selenium disulphide shampoo are also effective, as is
oral itraconazole (1200 mg/day) for 715 days.
TINEA (RINGWORM) INFECTIONS

Trichophyton, Microsporon and Epidermophyton species are responsible for this
group of dermatophyte infections. Trichophyton rubrum, T. mentagrophytes and
Epidermophyton occosum are the most common causes of dermatophyte infection in humans. Microsporon canis caught from dogs, cats or children causes tinea
capitis in children and, uncommonly, other types of ringworm infection. Occasionally, a quite inammatory ringworm can be caught from cattle (T. verrucosum) and horses (T. equinum).
The diagnosis is conrmed by microscopy of skin scrapings, hair or nail clippings treated with 20 per cent potassium hydroxide for 20 minutes and identication of fungal hyphae. Use of the cyanoacrylate skin surface biopsy technique
described above makes identication quite easy (Fig. 4.4).
Culture may be positive when direct microscopy is not, but it takes 23 weeks
or longer before the culture is ready to read.
Clinical features of ringworm infection
Tinea corporis
This is ringworm of the skin of the body or limbs. Pruntic, round or annular, red,
scaling, well-marginated patches are typical (Fig. 4.5). It has to be distinguished
Figure 4.4 Periodic acid-Schiff-positive fungal mycelium

hyphae in skin surface biopsy.
Figure 4.5 Well-demarcated scaling patch due to

ringworm.
39
Skin infections
Figure 4.6 Ringworm of

the groin (tinea cruris).
from patches of eczema or psoriasis by history and the presence of mycelium in

the scales. Any of the species may cause this condition. When an animal species is
responsible (e.g. T. verrucosum), the affected skin is very inamed and pustular
and heals spontaneously after a few weeks.
Tinea cruris
Tinea cruris or groin ringworm is very itchy and is for the most part a disorder of
young men. Well-dened, itchy, red scaling patches occur asymmetrically on the
medial aspects of both groins (Fig. 4.6). These gradually extend down the thigh
and on to the scrotum unless treated. T. rubrum and E. occosum are the causative
fungi. Differential diagnosis includes seborrhoeic dermatitis or intertrigo (see
page 116) where the rash is symmetrical and does not have a well-dened border,
and exural psoriasis.
Tinea pedis
Ringworm infection of the feet may be:
1 vesicular, with itchy vesicles occurring on the sides of the feet on a background
of erythema;
2 plantar, in which the sole is red and scaling; or
3 interdigital, in which the skin between the fourth and fth toes in particular is
scaling and macerated.

Tinea pedis is very common and particularly so in young and middle-aged
men, who often contract it from communal changing rooms. It tends to be itchy
and persistent. T. rubrum, in particular, but also T. mentagrophytes and E. occosum
cause the infection.
Tinea manuum
This less common, chronic form of ringworm usually involves one palm only,
which is usually dull red with silvery scales in the palmar creases. T. rubrum is usually to blame.
40
Figure 4.7 Scaling area

with hair loss in tinea
capitis.
Tinea capitis
Ringworm of the scalp occurs in children exclusively and is mainly due to M. canis.
It invades the scalp stratum corneum and the hair cuticle (ectothrix infection),
causing pink, scaling patches on the scalp skin and areas of hair loss due to the
breakage of hair shafts (Fig. 4.7). It is easily spread by, for example, the sharing of
hairbrushes. Infected areas sometimes uoresce a light green under long-wave
UVR (the so-called Woods light).
In another variety of scalp ringworm caused by T. schoenleini, the fungus
invades the interior of the hair shaft (endothrix) and causes intense inammation
on the scalp, with swelling, pus formation and scalp scarring.
Tinea unguium
This condition is due to ringworm infection of the nail plate and the nail bed. The
fungi responsible are T. rubrum, T. metagrophytes or E. occosum. Infected nail
plates are discoloured yellowish or white and thickened (Fig. 4.8). Onycholysis
occurs and subungual debris collects (Fig. 4.8). The condition is much more common in the toenails than in the ngernails. Tinea unguium has to be distinguished
from psoriasis of the nails (see page 129).
Figure 4.8 (a) and (b) Thickened,

yellowish, irregular toenails in tinea
unguium.
(a)
(b)
41
Skin infections
Case 3
Dai had been a miner for many years and felt that was the reason he had chronic
ringworm affecting his toenails and the soles of his feet. He was fed up with
having itchy, scaly feet and ugly, thickened toenails and sought treatment. Various
creams were prescribed but did not help. Eventually, a 3-month course of oral
terbinane began to clear the problem.
Tinea incognito
This is extensive ringworm with an atypical appearance due to the inappropriate use of topical corticosteroids (Fig. 4.9). The corticosteroids suppress the
protective inammatory response of the skin to the ringworm fungus, allowing it
to spread and altering its appearance.
Treatment
For ordinary ringworm of the hairy skin, an imidazole-containing preparation

(such as miconazole, econazole and clotrimazole) used twice daily for a 34-week
period is usually adequate. Topical allylamines such as terbinane are also effective.
When multiple areas are affected in tinea unguium and tinea capitis and when
topical treatment has failed for some reason, one of the following systemic drugs
needs to be used.
Griseofulvin (500 mg b.d.) is only active in ringworm infections and has a low
incidence of serious side effects.
Ketoconazole (200 mg daily) is active in both yeast and dermatophyte infections. This drug should be reserved for patients with severe and resistant
Figure 4.9 Tinea unguium showing

extensive and unusual-looking infection
due to tinea incognito.
42
disease because of the possibility of serious hepatotoxicity and the occurrence

of other side effects, including rashes, thrombocytopenia and gastrointestinal
disturbances.
Itraconazole (100 mg daily), like ketoconazole, is effective in both yeast and
dermatophyte infections. Serious side effects are uncommon.
Terbinane (250 mg daily) is indicated for dermatophyte infections only.
Serious side effects are uncommon.
These agents are administered for 26 weeks except for griseofulvin, which, when
given for tinea unguium of the toenails, may need to be given for 612 months.
Candidiasis (moniliasis, thrush)
This common infection is due to a yeast pathogen (Candida albicans) that resides
in the gastrointestinal tract as a commensal. It is a not infrequent cause of vulvovaginitis in pregnant women, in women taking oral contraceptives and in those
taking broad-spectrum antibiotics for acne. It is also responsible for some cases of
stomatitis in infants and the cause of infection of the gastrointestinal tract and
elsewhere in immunosuppressed people. It may contribute to the clinical picture
in the intertrigo seen in the body folds of the obese and in the napkin area in
infancy. Treatment with the imidazole preparations, topical and systemic, is effective. Oral and vaginal moniliasis responds to preparations of nystatin and
amiphenazole as well as to the imidazoles. Serious Candida infections respond to
systemic uconazole.
DEEP FUNGUS INFECTION

There are several fungal species that cause deep and sometimes life-threatening
infection. They are much more common in immunocompromised patients,
including those with autoimmune deciency syndrome (AIDS), transplant
patients, those on corticosteroids or immunosuppressive agents and those with
congenital immunodeciencies. Some, such as histoplasmosis, cryptococcosis and
coccidioidomycosis, are widespread systemic infections, which only occasionally
involve the skin.
Actinomycosis, sporotrichosis and blastomycosis infect the skin and subcutaneous tissues, causing chronically inamed hyperplastic and sometimes eroded
lesions. Sporotrichosis may produce a series of inamed nodules along the line of
lymphatic drainage. Deep fungus infections of this type produce a granulomatous
type of inammation, with many giant cells and histiocytes as well as polymorphs
and lymphocytes.
Madura foot is a deep fungus infection of the foot and is seen in various countries of the African continent and India. The affected foot is swollen and inltrated by inammatory tissue, with many sinuses. The infection spreads throughout
the foot, invades bone and is very destructive and disabling.
43
Skin infections

ACUTE BACTERIAL INFECTION
Impetigo contagiosa
Impetigo is a contagious, supercial skin infection caused by Staphylococcus aureus

in most instances and perhaps by the haemolytic Streptococcus in a few cases.
Clinical features
Red, sore areas, which may blister, appear on the exposed skin surface (see
Fig. 4.10). Yellowish gold crust surmounts the lesions that appear and spread
within a few days. It is mostly a disorder of prepubertal children. It is, however, not
uncommon for the signs of the lesions to appear over an area of eczema. The condition is then said to be impetiginized.
In tropical and subtropical areas, an impetigo-like disorder is spread by ies
and biting arthopods. This disorder is more destructive than ordinary impetigo
and produces deeper, oozing and crusted sores and is caused mostly by betahaemolytic streptococci. It is sometimes known as ecthyma.
There have been several outbreaks of acute glomerulonephritis following
episodes of this infective disorder.
Treatment
Local treatment with an antibacterial wash to remove the crust and debris, as well
as a topical antimicrobial compound such as betadine or mupirocin are needed in
all cases and, unless the area is solitary and very small, a systemic antibiotic such
as penicillin V (250 mg 6-hourly for 7 days) is also required. Patients usually
respond within a few days.
Erysipelas
Erysipelas is a severe infective disorder of the skin caused by the beta-haemolytic

Streptococcus.
Figure 4.10 Patch of

impetigo on the nose.
44
Figure 4.11 Severely

inamed erythematous
area on the thigh due to
erysipelas.
There is sudden onset of a well-marginated, painful and swollen erythematous

area, usually on the face or lower limbs (Fig. 4.11). The inammation may be very
intense and the area may become haemorrhagic and even blister. There is usually
an accompanying pyrexia and malaise.
Treatment with antibiotics by mouth (penicillin V, 250 mg 6-hourly) should be
rapidly effective.
Cellulitis
This is a diffuse, inammatory disorder of the subcutis and skin caused by several
different micro-organisms and is of variable severity.
It is relatively common, particularly on the limbs, and often occurs on legs
affected by venous ulceration or by lymphoedema. There is pain, tenderness,
slight swelling and a variable degree of diffuse erythema.
Broad-spectrum antibiotics are indicated, as the micro-organisms may be
Gram negative in type (e.g. Escherichia coli) or Gram positive. Cephradine and
ucloxacillin (250 mg of each 6-hourly) are one suitable combination.
FURUNCLES (BOILS) AND CARBUNCLES

Both these lesions result from Staphylococcus aureus infection of hair follicles.
They are much less common now than 30 or even 20 years ago, presumably
because of improved levels of hygiene. Nonetheless, there are still families and
individuals who are troubled by recurrent boils. In many instances, the pathogenic Staphylococcus colonizes the external nares, the perineum or other body sites
and is difcult to dislodge. The lesions are localized, red, tender and painful
swellings; carbuncles may be quite large, perhaps 3 or 4 cm in diameter, and represent the infection of several follicles.
When there is pus centrally, surgical drainage is indicated. Systemic antibiotics
are required and, whenever possible, their use should be guided by the pattern of
sensitivities found by culture.
45
Skin infections
ANTHRAX
Anthrax is due to a rare, potentially fatal infection with a Gram-positive bacillus
(Bacillus anthracis) causing black, scabbed sores and septicaemia. It is spread by
farm animals and, because the micro-organism has a resistant spore form, can
stay on infected land for years. It has assumed a major importance because of its
deliberate spread by terrorists in the USA.
TUBERCULOSIS
Tuberculosis is a multi-system disease caused by varieties of the waxy-enveloped
bacterium Mycobacterium tuberculosis. Several types of skin tuberculosis were once
commonly seen, but are now quite rare in developed countries. However, tuberculosis is, unfortunately, now once again becoming quite common because of the
appearance and spread of AIDS. The bacillus can be cultured in special media in
vitro, but grows very slowly. Special stains are needed to detect it in tissue.
LUPUS VULGARIS
Lupus vulgaris is a rare disorder causing a slowly progressive, granulomatous
plaque on the skin caused by the tubercle bacillus. It slowly increases in size, over
one, two or three decades. It often has a thickened psoriasiform appearance, but
blanching with a glass microscope slide (diascopy) will reveal grey-green foci
(apple jelly nodules) due to the underlying granulomatous inammation.
Treatment is initially with triple therapy of rifampicin, pyrazinamide and isoniazid over a 2-month period, followed by a continuation treatment phase with
isoniazid and pyrazinamide.
Tuberculosis verrucosa cutis (warty tuberculosis)
This is seen on the backs of the hands, knees, elbows and buttocks whenever abrasive contact with the earth and expectorated tubercle bacilli has been made.
Thickened, warty plaques are present, which are sometimes misdiagnosed as
viral warts. Diagnosis is conrmed by biopsy showing tuberculoid granulomata
and caseation necrosis.
Treatment is as for lupus vulgaris.
Other forms of cutaneous tuberculosis
A persistent ulcer may arise at the site of inoculation as a primary infection.

An eroded, weeping area with bluish margins often develops where a tuberculous
sinus drains onto the skin from an underlying focus of tuberculosis infection.
Tuberculides may develop as hypersensitivity to the tubercle bacillus. In papulonecrotic tuberculide, papules arise and develop central necrosis with a black
crust. Erythema induratum is an uncommon, odd disorder, which in many cases
appears to full the criterion of being a response to tuberculous infection. It is
46
characterized by the development of plaque-like areas of induration and necrosis

on the lower calves and occurs predominantly in young women.
SOME OTHER MYCOBACTERIAL INFECTIONS

Swimming pool granuloma
Mycobacterium marinum, which lives in water, is sometimes caught from swimming pools and sh tanks. It has a 3-week incubation period and causes plaques,
abscesses and erosions on the elbows and knees in particular.
The condition responds to minocycline or a trimethoprimsulphamethoxazole
combination.
Buruli ulcer
Mycobacterium ulcerans is responsible for this disorder occurring in Uganda and

south-east Asia. Large, undermined ulcers form quite rapidly and persist. Surgical
removal is currently the best treatment.
SARCOIDOSIS
Recent data suggest that the disorder is, in many patients, an unusual reaction to
M. tuberculosis. Sarcoidosis is a multi-system disease with manifestations in the
respiratory system, the reticuloendothelial system and the skin and occasionally
in the bony skeleton and central nervous and cardiovascular systems. In the skin,
one of the most common varieties consists of multiple, reddish purple papules
(Fig. 4.12). Deeper nodules and plaques are also seen, as are bluish chilblain-like
Figure 4.12 Multiple papules and

nodules of the skin of the thighs due to
cutaneous sarcoidosis.
47
Skin infections
swellings of the ngers, nose and ears (lupus pernio). These types are inltrated
by typical sarcoid tissue (see below), but another manifestation, erythema
nodosum (see page 77), is not.
Histologically, the typical lesion is the naked tubercle, which contains foci of
macrophages and giant cells without many surrounding lymphocytes.
Treatment may not be required if the lesions are not troublesome, as they are
self-healing, but when large they may leave scarring. For these large lesions,
systemic corticosteroids or non-steroidal anti-inammatory agents may be
required.
LEPROSY (HANSENS DISEASE)

This is caused by a slow-growing bacillus of the mycobacterial type (M. leprae),
which cannot be grown in vitro, although it can be passaged in armadillos and
small rodents. As with the tubercle bacillus, it is detected in tissue by the
ZiehlNielsen stain or by an immunocytochemical test. The disease is spread by
droplet infection and by close contact with an infected individual. It is still a serious problem globally, with 12 million people affected, mostly in the poor and
underprivileged countries of Africa and Asia.
Clinical features
The pattern of involvement is much dependent on the immune status of the individual. The two extremes are the lepromatous form seen in anergic individuals
and the tuberculoid form seen in individuals with a high resistance. Because there
are many gradations between these polar types, the range of clinical signs and the
corresponding nomenclature have become very complicated. Where the changes
are near tuberculoid, the term borderline tuberculoid is used; similarly borderline lepromatous is used for lesions that are close to the other type. Dimorphic
refers to both types of lesion being present. In tuberculoid lesions, nerves are
infected, which become thickened. The affected areas are well dened, macular
and hypopigmented, as well as being anaesthetic because of the nerve involvement. The anaesthesia results in injury, deformity and disability. In lepromatous
leprosy, the infection is much more extensive, with thickening of the affected
tissue as well as surface changes, with some hypopigmentation. On the face, the
thickening gives rise to the characteristic leonine facies, with accentuation of the
soft tissues of the nose and supraorbital areas. Where there is resistance, few
bacteria can be detected in the lesions (paucibacillary types of leprosy). Types
in which many bacteria are found and the patients are anergic are known as
multibacillary.
In general, the disease can produce dreadful deformity and disability unless
skilfully treated, and it still evokes great fear in primitive communities. Because
the disorder causes patchy hypopigmentation, the differential diagnosis includes
vitiligo pityriasis versicolor and pityriasis alba.
In tuberculoid types, there is a striking granulomatous inammation with
many giant cells and only a few M. leprae to be found. In the lepromatous types,
48
there are many macrophages that are stuffed with M. leprae (causing the appearance of foamy macrophages).
Treatment
The treatment of choice is with dapsone (100 mg daily, for periods of a minimum
of 6 months) with rifampicin (600 mg monthly) for paucibacillary types of leprosy. During treatment, the patients condition may are and deteriorate, causing
curious appearances in some, including erythema nodosum-like and ichthyosislike reactions. Multibacillary types should also be treated with dapsone (100 mg
daily) and in addition rifampicin (600 mg once monthly) and clofazimine (50 mg
daily). Drug resistance is becoming a major problem.
LYME DISEASE
Lyme disease is caused by the Borrelia burgdori micro-organism, which is spread
by the bite of a tick and has been described in several areas of Europe, including
the UK, and in the USA. The disorder is multi-system in that there may be
arthropathy, cardiovascular and central nervous components, as well as systemic
upset. The skin may be involved in the early stages and show an erythematous ring
that expands outwards (erythema chronicum migrans). Later, skin atrophy may
be seen (acrodermatitis chronica atrophicans), or brosis in a morphoea-like
condition. Diagnosis is made by identication of the organism in the tissues or by
detection of antibodies in the blood.
Treatment is with antibiotics preferably penicillin.
LEISHMANIASIS
The term refers to a group of diseases caused by a genus of closely related protozoal parasites with complex life cycles, which include time spent in small rodents.
These diseases are spread by biting arthropods (mostly sandies) in tropical and
subtropical areas. Some forms cause severe systemic disease and are prevalent in
some areas of Africa and South America and the Indian subcontinent: Others
cause predominantly cutaneous or mucocutaneous disease.
Cutaneous forms are found around the Mediterranean littoral and North Africa
and in South America. The Mediterranean type is caused by Leishmania major
and L. tropica. After an incubation period of about 2 months, a boil-like lesion
appears, usually on an exposed site (Baghdad boil). Later, this breaks down
to produce a sloughy ulcer (oriental sore: Fig. 4.13), which persists for some
months before healing spontaneously, with scarring and the development of
immunity.
Mucocutaneous forms occur mainly in South America (New World leishmaniasis)
and are due to L. mexicana and L. brasiliensis. Small ulcers develop (Chicleros
ulcer) that seem more destructive than the Old World types but also more
49
Skin infections
Figure 4.13 Cutaneous leishmaniasis in

a boy, showing persistent plaque and
papules on the skin of the cheek.
persistent, and later in the disease destructive lesions appear, affecting nasal
mucosa in about half of the patients.
A cutaneous component to visceral forms is less common, but more extensive,
and includes a diffuse cutaneous form with many plaques and nodules resembling
lepromatous leprosy, a recidivans form with persistent plaques resembling lupus
vulgaris, and post kala-azar (dermal leishmaniasis), occurring after the visceral
disease and marked by the appearance of numerous small papules.
Biopsy shows mixed granulomatous inammation. The parasites can be identied by special stains and can also be cultured in specialized media. There is also
an intracutaneous skin test (leishmanin), which becomes inamed after injection
in most patients.
Treatment
The localized small ulcers heal spontaneously, but can be treated by freezing or
curettage. Inltration with sodium stibogluconate has been used. Systemic sodium
stibogluconate or pentamidine may also be used for severe and resistant cases.

HERPES SIMPLEX
This is caused by a small DNA virus of two antigenic types, I and II. Type II herpes simplex infects the genitalia and type I is responsible for the common herpetic
infection of the face and oropharynx and, less commonly, elsewhere.
The initial infection may be quite unpleasant, with severe stomatitis, systemic
upset and pyrexia mostly in infants. Resolution takes place in about 10 days.
Reactivation of the herpes infection occurs in some cases, at varying intervals.
Up to 20 per cent of the population suffers from recurrent cold sores, so named
50
Figure 4.14 Herpes

simplex (cold sore) on
the lip, with a crust and
vesicles.
because the disorder is often precipitated by minor pyrexial disorders. It may also
be precipitated by sun exposure. Commonly, the lesions occur around the mouth
or on the lip. They start as grouped, tender and/or painful papules or papulovesicles (Fig. 4.14) and then coalesce to form a crusted erosion. The sequence takes
some 714 days from initial discomfort to the nal pink macule marking where
lesions have been.
Genital herpes affects the glans penis and the shaft of the penis. In women, the
vulval region or labia minora is usually involved, but lesions may occur elsewhere
on the buttocks or mons pubis. It may occur cyclically with the menses.
The disorder is caught venereally and has become extremely common. It is
painful and inhibits sexual activity.
The vesicle results from epidermal cell degeneration, and smears taken from
the lesion showing degenerate cells may help in diagnosis. The diagnosis can also
be made by identifying the virus using an immunouorescent method with antibodies to the herpes virus.
Treatment
Most patients do not require treatment. Idoxuridine is a viral metabolic antagonist,

which, as a 5 per cent lotion, can shorten the disorder if started early and used
frequently. Aciclovir (5 per cent cream) is the most effective agent for shortening the
attack if started early and used ve or six times per day. Aciclovir can also be used
orally, (200 mg ve or six times per day) in severe infections. Famiciclovir has similar properties.
HERPES ZOSTER (SHINGLES) AND CHICKEN POX (VARICELLA)

The same small DNA virus causes both these disorders, which differ only in the
extent of the disease, the symptoms caused and the immune status of the individual affected. Most (but not all) cases of chicken pox (varicella) develop during
infancy or childhood. Reactivation of the virus occurs in a proportion of those
previously affected and causes shingles.
51
Skin infections
VARICELLA
This common childhood ailment is spread by droplets and debris from the lesions
and has an incubation period of 1421 days. There is accompanying fever and
malaise. Lesions are common on the face and trunk, but less common on the
limbs. Papules and papulovesicles become crusted, the crust dropping off after
some 714 days, leaving pock-type scars in many instances.
HERPES ZOSTER (SHINGLES)

This mostly aficts those past the age of 50 years, but also affects immunosuppressed individuals such as patients with AIDS. It is not caught, but is due to the
reactivation of a virus that has been sitting latent in a posterior root ganglion of
a spinal nerve. Although shingles is not caught from patients with shingles,
chicken pox is.
The disorder often starts with paraesthesiae or pain in the distribution of
one or more dermatomes. Involvement of one of the branches of the trigeminal
ganglion, with lesions in the distribution of the maxillary, mandibular or ophthalmic sensory nerves, is common, as is involvement of dermatomes of the cervical and thoracic regions. Lesions are conned to the skin innervated by the
dorsal primary root(s) infected (Fig. 4.15), although there may be a small number
of lesions elsewhere. About 2530 per cent of patients with shingles continue
(a)
Figure 4.15 (a) Herpes zoster of the

axillae and chest wall showing clusters
of vesicles and pustules. (b) Herpes
zoster affecting the ophthalmic branch of
the trigeminal nerve involving the right
side of the forehead and eye.
(b)
52
to suffer from pain and paraesthesiae in the area long after the skin lesions have
disappeared.
Herpes zoster may occur where there is immunosuppression, as in AIDS or a
lymphoma. When this occurs, the disorder is often very severe and may involve
several dermatomes.
For most people, no specic treatment is required apart from keeping the
lesions clean and, if necessary, the application of antimicrobial preparations to
prevent or combat secondary infection. The drug aciclovir, administered by
mouth in a dose of 800 mg ve times daily (or by infusion) on day 1 of the disorder, shortens the disease and decreases its severity.
VIRAL WARTS
Warts are caused by a member of the human papillomavirus family, of which
there are many antigenic types (Table 4.1). Particular clinical types of wart are
caused by particular antigenic types. It is likely that they are caught by direct
contact of skin with wart virus-containing horny debris. Genital warts are caught
mostly (but not exclusively) by venereal contact. Some perianal warts may be
transmitted by homosexual contact or by child abuse.
The different varieties are illustrated in Figure 4.16. There are usually little
black dots near the surface of the wart, representing thrombosed capillaries in
elongated dermal papillae.
Plantar warts are painful, some warts are irritating, and all warts are unsightly
and aggravating. They are a particular problem in immunosuppressed patients.
In one congenital condition, plane warts spread extensively on the arms, face, trunk
Table 4.1 Human papillomavirus (HPV) types and the common clinical varieties of
warts with which they are associated
Clinical type
Most common antigenic type of

HPV associated
Common warts of hands and ngers

(verruca vulgaris)
2, 4
Deep plantar warts (myrmecia warts)
Plane warts
3, 10
Mosaic warts
Epidermodysplasia verruciformis
5, 8 (but many others isolated on

occasion)
Genital warts (condyloma

acuminatum)
6, 11 (NB. Types 16 and 18 are also

responsible occasionally, and these are
known to be associated with carcinoma
of the cervix)
Laryngeal papilloma
6, 11
53
Skin infections
(a)
(b)
(d)
(e)
(c)
Figure 4.16 (a) Typical viral warts of nger. (b) Large paronychial viral wart. (c) Mosaic wart. (d) Perineal warts in an
adult. (e) Multiple penile warts.
54
Figure 4.17 Photomicrograph of a viral

wart showing marked hypergranulosis
and vacuolar change in thickened
epidermis.
Figure 4.18 Single lesion of molluscum

contagiosum showing central plug.
and limbs and some lesions can transform to squamous cell carcinoma. This rare
disorder, known as epidermodysplasia verruciformis, seems to have its basis in a
disorder of delayed hypersensitivity.
There is epidermal thickening, with particular increase in the granular cell
layer, which also shows a characteristic basophilic stippled appearance (Fig. 4.17).
All warts disappear spontaneously, but may persist for many months or some
years. Treatment is, in general, not very satisfactory and relies on some form of
local tissue destruction. The techniques mostly used are cryotherapy (tissue freezing with liquid nitrogen or solid carbon dioxide), curettage and cautery or chemical destruction with topical preparations containing salicylic acid, lactic acid,
podophyllin or glutaraldehyde. Popular preparations contain high concentrations
of salicylic acid (1220 per cent) and lactic acid (420 per cent) or podophyllin (up
to 15 per cent). Podophyllin is a plant extract containing potent cytotoxic alkaloids,
one of which, podophyllotoxin, is also available as a pure preparation (0.5 per
cent). Other methods that have been used include intracutaneous injections of
cytotoxics such as bleomycin and injections of recombinant interferon.
MOLLUSCUM CONTAGIOSUM
Molluscum contagiosum is a common infection of the skin caused by a virus of
the pox virus group. It is transmitted by skin-to-skin contact.
The typical molluscum lesion is a pink-coloured or skin-coloured, umbilicated
papule containing a greyish central plug (Fig. 4.18). There may be one or many
lesions. The face and genital regions are commonly involved.
55
Skin infections
Figure 4.19 Photomicrograph of molluscum

contagiosum showing thickened epidermis with central
degenerative change and formation of molluscum
bodies.
Figure 4.20 Area of orf infection on the thumb.
Pathology
There is cup-shaped epidermal thickening with a characteristic degenerative

change in the granular cell layer, in which the cells become converted to globular
eosinophilic bodies (molluscum bodies: Fig. 4.19).
Mollusca spontaneously resolve within months of curettage and cautery, strong
salicylic acid preparations as for warts or simply squeezing the soft centre out (e.g.
with a paper clip).
ORF (CONTAGIOUS PUSTULAR DERMATITIS OF SHEEP)

This disorder is caused by a pox-type virus that mostly affects sheep but also
cattle. The lesions are solitary, acute, inammatory and blistering and are mostly
on the ngers (Fig. 4.20). Following the attack, a surprisingly high proportion
of patients develop erythema multiforme (see page 75).
Summary
The normal ora of the skin consists of
Gram-positive cocci (Staphylococcus epidermidis)
Gram-positive rods (Propionibacterium acnes)
and Gram-positive yeasts (Pityrosporum ovale).
Pityriasis versicolor is caused by Pityrosporum ovale
when there is depressed immunity or when there is
heightened sebum secretion. Fawn, scaling macules
occur over the trunk. Treatments with imidazole
creams or itraconazole by mouth are effective.
Tinea infection (ringworm) is caused by

Trichophyton, Epidermophyton and Microsporum
species of fungus and is restricted to the stratum
corneum, the hair and nails. Diagnosis is
conrmed by identifying the fungi in the scales
by direct microscopy and culture. Tinea pedis,
tinea cruris and tinea unguium, affecting the feet,
groin and nails, respectively, are the most
frequently encountered. Treatments with topical
56
Summary
imidazoles, topical terbinane or oral terbinane

are suitable.
Candidiasis caused by Candida albicans causes
vaginal and oral thrush and complicates napkin
dermatitis and intertrigo.
Impetigo caused by Staphylococcus aureus results
in red, sore areas that may blister and later develop
a characteristic yellow crust.
Infection with beta-haemolytic Streptococcus is
the cause of erysipelas, which is characterized
by a sharply marginated, painful, red, swollen
area with severe malaise and pyrexia. Cellulitis
is a more diffusely swollen area due to bacterial
infection.
Lupus vulgaris and tuberculosis verrucosa cutis are
disorders caused by infection with the tubercle
bacillus.
Sarcoidosis is a multi-system disease that may
represent a hypersensitivity to the tubercle bacillus
and often results in persistent papules and nodules
on the skin.
Leprosy is caused by Mycobacterium leprae. The
clinical manifestations depend on the immune
response. Tuberculoid forms are found in patients
with a strong immune response and lepromatous
forms where there is a poor immune response.
The disorder is still a problem for poor

communities. Treatment is with dapsone, rifampicin
and clofazimine.
Leishmaniasis is caused by protozoa that
reside in rodents and are spread by sandies.
In Europe, the commonest form is a persistent
ulcer caused by Leishmania tropica or Leishmania
major.
Herpes simplex is caused by a small DNA virus
that produces intraepidermal vesicles around
the mouth and lips (Type I) or on the genitalia
(Type II).
Herpes zoster and varicella are caused by the
same virus. Zoster is a painful disorder in which the
skin supplied by one (or two) dorsal nerve root is
involved in someone who has had varicella
previously.
Viral warts are caused by the human
papillomavirus, of which there are many
antigenic types. Particular antigenic types cause
particular sorts of wart. Treatment is by some
form of local destruction chemical, physical or
surgical.
Molluscum contagiosum causes small, pearly,
umbilicated papules and is the result of infection
with a member of the pox virus group.
57
C H A P T E R
Infestations, insect bites

and stings
Scabies
58
Pediculosis
63
65
69
Summary
70
The way that the skin reacts to the hostile attentions of arthropods and small
invertebrates depends partly on the extent and severity of the attack and particularly on the immune status of the individual attacked.
Each geographical region has its own spectrum of skin problems due to the local
fauna. Although some disorders, such as scabies, are the same the world over, the
pattern and incidence of infestations and bites differ markedly from place to place.
In general, the extent of skin problems due to arthropods is directly related to
the sophistication and wealth of the society in question, because of the effects of
personal hygiene, education, effective waste disposal and prophylaxis.
Scabies
Scabies is due to infestation with the human scabies mite (Acarus hominis,
Sarcoptes scabiei). The mite is an obligate parasite and has no separate existence
off the human body.
AETIOLOGY AND EPIDEMIOLOGY

The female mite burrows into the human stratum corneum and lays eggs within the
burrow made. The male is smaller than the female and dies shortly after impregnating the female. The symptom of itch and the characteristic eczematous rash
caused by invasion of the scabies mite are the result of the affected individual
becoming sensitive to the waste products of the mites within the intracorneal
58
Scabies
Figure 5.1 Papules and excoriations in scabies.
Figure 5.2 Multiple papules and vesicles due to scabies.
burrows. This generally does not happen before 1 month after the initial invasion
of the mite; subsequent infestations cause symptoms and signs within a few days
as the individual is already sensitized.
Infestation occurs after close skin-to-skin contact with an infested individual,
sexual contact being the most frequent but not the only cause of infestation.
There have been several notable pandemics of scabies in recent history. The
most recent of these started in the mid-1960s and ended in the early 1970s,
although between peaks of incidence the disorder continues to appear sporadically
and in localized mini-epidemics such as within families or in nursing homes.
CLINICAL FEATURES
The disorder is notorious for the intensity of itch that it causes, even in the presence of relatively minor physical signs. The physical signs are essentially those
of eczema and the effects of scratching. Vesicles are seen, but excoriations and
prurigo-like papules are more common (Figs 5.1 and 5.2). Scaling, oozing and
crusting can also be present in some sites due to secondary infection. However, the
primary lesion is that of the scabies burrow or run, which is a tiny, raised, linear
or serpiginous white mark (Fig. 5.3).
The favourite sites for lesions are portrayed in Figure 5.4. It is odd that they
should be symmetrical and concentrated in certain sites consistently. The best
sites on which to nd scabies burrows are the palms and the interdigital areas of
the ngers, the exural creases and over the elbows. Scabies lesions also commonly occur around the anterior axillary fold, the areolae of the breast, the buttock folds, lower abdomen, genitalia, knees, ankles and soles. Lesions are observed
on the head and neck in infants only.
The severity of the eruption depends on the number of mites present and this
is mostly dependent on the immune status of the individual. In severely immunosuppressed individuals, such as those with human immunodeciency virus (HIV)
Figure 5.3 Scabies burrow

on the foot.
59
Infestations, insect bites and stings
Figure 5.4 Diagrams

showing sites of predilection
for scabies infestation on
(a) the front of the trunk
and limbs, and (b) the back
of the trunk and limbs.
(a)
(b)
infection or patients receiving immunosuppressive drugs for renal transplants,

the infestation is very heavy and the resulting eruption correspondingly severe.
Norwegian scabies is the term used to describe a very severe and extensively
crusted version of the infestation seen in the frail elderly and congenitally immunodecient population (Fig. 5.5).
DIAGNOSIS
The diagnosis of scabies is not always easy, but is much helped by nding the burrows of the female scabies mite, which are pathognomonic of the disease and their
recognition is important. The burrows are grey-white, linear, slightly raised
marks, some 14 mm long, and are present on the favoured sites. The number of
burrows present is variable myriads in severe infestations in the elderly, but few
in the fastidiously hygienic young.
60
Scabies
Figure 5.5 Severely

crusted eruption due
to scabies in an
immunosuppressed child.
Figure 5.6 Scabies mite

seen by microscopy in
skin scrapings treated
with potassium hydroxide.
Finding the mite (or its eggs) by using a pin or by examining skin scrapings
(Fig. 5.6) or a skin surface biopsy taken with cyanoacrylate glue conrms the diagnosis (Fig. 5.7).
Identication of the telltale burrows or mite is not always easy, even for the
experienced! For the 20 per cent of scabies patients in the UK in whom burrows
cannot be identied, a positive family or social history with itching contacts is
helpful evidence and, in the presence of a compatible clinical picture, treatment
should be instituted. Differential diagnosis is set out in Table 5.1.
Figure 5.7 Scabies mite

seen on microscopic
examination of skin
surface biopsy.
TREATMENT
Treatment should be instituted as soon as the diagnosis has been made to prevent
the infestation spreading. It should also be offered to everyone who lives with the
61
Table 5.1 Differential diagnosis of scabies

Disorder
Comment
Canine scabies
Different distribution not transmitted between

humans
Eczematous diseases
Particularly atopic dermatitis usually a history of

eczema is present for the patient or family
Similar distribution; vesicles and urticarial lesions

more prominent biopsy discriminates
Mechanical irritation by
breglass
The glass bres can be found microscopically in

clothes
Pediculosis
Presence of lice and nits
Table 5.2 Treatments used for scabies

Agent
Percentage
Comment
Malathion
0.5
Second line treatment
Permethrin
1.0
New effective agent
Crotamiton
10.0
Claimed to be antipruritic as well
Monosulram
25.0
May cause Antabuse (disulram)-like

alcohol reaction
patient and to all other sexual contacts, who should use the treatment at the same
time as the patient.
The treatments employed are applied to the whole skin surface apart from
the head and neck, and are for this reason usually lotions, although creams are
also sometimes used. The patient should be instructed to have a hot bath before
applying the treatment, after which no further application or bathing is permitted
for 24 hours. The particular agents used are set out in Table 5.2.
Case 4
Sydney was 35 and began to itch all over two weeks ago. Now his girlfriend was
also itching, as were her mother and brother. Close inspection of the skin showed
many excoriations. Over the buttocks and genitalia there were papules and tiny,
whitish lines, at the end of which there were minute black specks. Microscopy of
these showed them to be scabies mites. Sydney was given permethrin lotion and
told to use it all over from the neck down after a hot bath. His girlfriend and her
family were also given the treatment. Improvement in the itching started some
2 weeks later.
62
Pediculosis
DOG SCABIES
The mite causing dog scabies is similar to that causing human scabies, but the dog
scabies mite does not cause the same clinical picture as human scabies. The rash
only occurs at the site on the skin with which the dog has been in contact and does
not spread to other areas. Scabies burrows are not found. The correct treatment is
to treat the dog and to give any topical anti-itch preparation to the patient for the
affected site.
Pediculosis
Pediculosis is the result of infestation with one of the varieties of the human louse.
The different varieties cause different patterns of infestation.
PEDICULOSIS CAPITIS (HEAD LICE)

Infestation with Pediculus capitis is extremely common and seems to be becoming
even more so. Although once more often seen in the poorer sections of society,
the head louse is now seen in long-haired schoolchildren regardless of social
background. It is more common during times of social upheaval, such as war. The
louse is passed amongst children by casual contact and by sharing combs and
brushes.
Clinical features
Itching is the predominant complaint. The scratching that results can cause secondary infection with exudation and crusting, but if this does not occur, all that
may be seen are excoriation and red papules on the skin surface.
Examination of the hair will reveal the louse eggs (nits) stuck to the hair shaft
(Fig. 5.8). Careful inspection will also detect the adult louse itself, which is less
than 1 mm long and greyish or, after feeding, reddish in hue. When it moves it
deserves the description of mobile dandruff .
Conrmation of the diagnosis is the microscopic identication of the louse
(Fig. 5.9) or the nits stuck to the hair shafts.
Figure 5.8 Louse egg (nit)

on hair.
Treatment
The pediculicides used are set out in Table 5.3. The recommended regimen is
application to the scalp of malathion or carbaryl lotion for a 12-hour period, followed by shampooing with shampoo containing the same pediculicide. Care must
be taken to ensure that all close friends and family are also treated. A further treatment 1 month later is also necessary to kill off all the young lice that may have
hatched from nits that remained alive after the initial treatment.
Figure 5.9 Hair louse seen

microscopically.
63
Table 5.3 Treatments for pediculosis capitis

Agent
Percentage
Comment
Malathion
Carbaryl
Phenothrin
0.5
0.5
0.2
Both lotion and shampoo

Both lotion and shampoo
Lotion
PEDICULOSIS CORPORIS (BODY LICE)

Infestation with body lice is uncommon in modern developed societies, but may
reach epidemic proportions in times of war or natural disaster. It also occurs sporadically in poor, socially deprived communities where there is poor hygiene.
Transmission is via infested clothes or bedding or by close contact with the
infested subject. The body louse is responsible for transmission of epidemic
typhus, which is due to Ricketessia prowazeki, as well as trench fever and relapsing
fever due to Borrelia recurrentis.
The body louse spends most of its time attached to the bres of clothing, where
it and its eggs should be sought if the disorder is suspected.
Clinical features
Itching without a great deal to see to account for the symptom is usual in the early
stages. Some excoriations, blood crusts and bluish marks on the skin where the
louse has fed may also be seen. Later in the disease, lichenication and eczema
complete the picture of vagabonds disease.
Treatment
Destruction and/or disinfestations of all clothes and bedding of the infested

individual, the individuals family, friends and close contacts are necessary.
In many countries, there are disinfestation centres where this essential task is
performed. Treatment with one of the pediculicides in Table 5.3 is mandatory.
A further treatment after 1 month is advised.
PEDICULOSIS PUBIS (PUBIC LICE, CRAB LICE)

The pubic louse (Phthirus pubis) looks different from the head and body lice as it
is broader, with crab-like rear legs (Fig. 5.10). It is mostly spread by sexual contact. The crab lice cling tenaciously to pubic hair, nipping down to skin level every
so often to have a blood meal. In heavy infestations, the lice spread to body hair
and even to the eyebrows and eyelashes! Diagnosis is conrmed by nding the
louse and/or its nits.
64
Figure 5.10 Pubic louse.
Treatment
One of the pediculicides in Table 5.3 should be used, with a repeat treatment after
1 month. Shaving of pubic hair is sometimes advised, but is not really necessary.
All sexual contacts should be treated.

A vast number of ying, jumping and crawling arthropods are capable of causing
injury in a variety of ways to human skin. Some are capable of transmitting
disease and some important examples of this are given in Table 5.4 (see also
Table 5.5).
MOSQUITOES
Mosquito bites tend to be on exposed areas. Some varieties of mosquito (e.g. the
culicine mosquitoes) can cause blisters when they bite. The bites may be extremely
itchy and prominent (Fig. 5.11) and may become infected after being scratched.
FLEAS
Flea bites are mainly sustained from cat and dog eas, which occasionally
temporarily visit a human host. They drop off their original hosts and live on
carpets and rugs, as do their young, and jump up when they feel the vibration of
footsteps. The bites, which are small and itchy, are often, but not exclusively, on
the legs.
65
Table 5.4 Examples of important arthropod-spread diseases

Disease
Arthropod
Micro-organism
Malaria
Mosquitoes
(Anopheles species)
Malaria parasite a
(Plasmodium species)
Trypanosomiasis
(sleeping sickness)
Tsetse y
Trypanosoma brucei a
Leishmaniasis
Visceral
Cutaneous
Mucocutaneous
Sandy
(Phlebotomus species)
Onchocerciasis
Blacky
(Similium species)
Onchocerca volvulus b
Bubonic plague
Rat ea
Pasteurella pestis c
Leishmania donovani a
Leishmania tropica a
Leishmania braziliensis a
Protozoon.
Thread-like nematode worm.
c
Bacterium.
b
Table 5.5 Examples of methods of injury to the skin by arthropods

Mechanism
Arthropod
Bites from piercing and cutting

mouthpieces injection of saliva
Mosquitoes, ticks, sandies, blackies
Stings from purpose-built structures

with injection of toxic materials
Wasps, bees, scorpions, jellysh
Release of toxic body uids after

being crushed on the skin surface,
causing blistering
Blister beetles cantharidin
Figure 5.11 Mosquito

bites on the leg.
66
TICKS
Ticks stay stuck to the skin for some time after biting and are found mainly in
agricultural communities, as the principal host is mostly sheep.
MITES
A large variety of mites may occasionally bite humans. Most of these, such as bird
mites or Cheyletellia mites living on cats, dogs and rabbits (amongst others), cause
small, red, itchy papules and are quite difcult to identify (Fig. 5.12).
BEDBUGS (CIMEX LECTULARIUS)

This primitive creature lives in the woodwork of old houses and comes out at
night to bite its sleeping victims. The bites are often quite large and inamed
and arranged in straight lines where the creature has taken a stroll over the skin
surface.
WASPS AND BEES

The stings of wasps and bees are usually quite painful. The stung part may become
very swollen a short time after the sting and, when hypersensitivity is present, the
individual may develop a widespread reaction. Rarely, such a reaction can cause
anaphylactic shock and even death.
PAPULAR URTICARIA
Papular urticaria is a term used to describe a recurrent, disseminated, itchy papular eruption due to either insect bites or hypersensitivity to them.
Figure 5.12 Multiple

small papules due to
mite bites.
67
Diagnosis
The lesions themselves should be compatible, i.e. they should be papules or, less
commonly, blisters, and it helps if puncture marks can be found in the lesion. It is
commonplace for the patients (or their parents) to deny the possibility of insect
bites being responsible for the lesions, as there seems to be a social stigma attached
to being the recipient of them. A detailed history is necessary, with particular
attention being given to the presence of domestic animals, proximity to farms,
the occurrence of similar lesions in other family members, and the periodicity of
lesions.
Biopsy may occasionally be helpful in that it may well rule out other disorders.
The presence of a mixed inammatory cell inltrate in the upper and mid
dermis is typical, but the pattern and density of cellular inltrate are variable
(Fig. 5.13).
Searching for the biting arthropod in the home may be fruitless unless the
assistance of trained personnel is sought. Examination of brushings from the
coats of dogs by veterinarians may be successful in identifying the culprit
cheyletellia, for example.
Treatment
Identication of the creature responsible and prevention of further attack are

important. Uncommonly, when there is evidence of hypersensitivity (as in a bee or
wasp sting), systemic antihistamines may be required and, when there is a severe
systemic reaction, systemic steroids and even adrenalin may be needed.
A major problem with insect bites is their intense itchiness. Occasionally, this
may result in infection in the excoriated skin, when treatment is required for
this complication. Topical antihistamines (e.g. diphenhydramine, promethazine,
dimentidine) are often prescribed and may have a slight antipruritic effect, but all
that is usually required is a calamine or mentholated calamine preparation.
Figure 5.13 Pathology of inspect bite showing marked

inammation and subepidermal oedema.
68

ONCHOCERCIASIS
This is caused by the parasite Onchocerca volvulus and is found in equatorial West
Africa. The disorder is spread by the bite of the blacky Simulium damnosum,
which is found around rivers. The larval forms, known as microlariae, are injected
into the skin by the blacky and develop after some years into adult onchocercal
worms. These are extremely long (up to 1 m) but very thin (12 mm in diameter)
creatures that live curled up in the subcutis surrounded by a palpable, host-supplied brous capsule. The adult worm procreates by producing enormous numbers of microlariae, which invade the subcutis of large areas of truncal skin.
Clinical features
The disorder is characterized by severe and persistent irritation of affected skin.

Affected areas become thickened, lichenied (see page 119), slightly scaly and
often hyperpigmented (Fig. 5.14). The microlariae may also invade the supercial tissues of the eye and cause blindness (river blindness).
Diagnosis
Biopsies show non-specic inammation, but occasionally demonstrate portions

of the microlariae. A more successful way of identifying the larval forms is by
taking a series of skin snips with a needle and scalpel. The tiny portions of skin
are then immersed in saline and observed microscopically to watch for the emergence of microlariae. There is usually a marked eosinophilia and there is also a
complement xing test for antibodies that is available in some centres.
Treatment
The pruritus is much improved by Hetrazan (diethyl carbamazine). The drug

must be given cautiously because of the possibility of a severe systemic reaction
Figure 5.14 Skin changes of onchocerciasis, with marked thickening and

discoloration.
69
due to the liberation of toxic products from the dying microlariae. Hetrazan has
no effect on the adult worm and it is necessary to treat with the potentially toxic
drug Suramin to kill off the worm and prevent further production of microlariae. Ivermectin is also helpful.
Summary
Scabies is caused by a tiny mite, the female of
which burrows into the stratum corneum. It is
extremely itchy and is caught by skin contact with
an infected individual.
The primary lesion is the scabies run or burrow,
at the end of which sits the mite. Excoriated papules
and vesicles are also seen. Affected sites include
palms, soles, knees, elbow, ankles and genitalia.
Heavy infestation occurs in immunocompromised
individuals, resulting in thick, crusted areas known
as Norwegian scabies.
Treatment is with permethrin or malathion, which
should be applied over the entire skin surface below
the neck after a bath and be used for all human
contacts.
Pediculosis is caused by infestation with the human
louse. Head lice (Pediculus capitis) cause
infestation of the hair and are common in

schoolchildren. Eggs (or nits) are found stuck to
the hair. Shampoos containing phenothrin or
malathion are used in treatment.
Pediculosis corporis is seen in the socially
deprived and is transmitted by clothes and
bedding. The body louse may transmit
typhus.
Pediculosis pubis (crab lice) is caused by Phthirus
pubis, which infests pubic hair and is spread
by sexual contact. Treatment is with phenothrin
or malathion applications.
Insect bites spread many disorders, including
malaria, leishmaniasis and onchocerciasis.
Mosquitoes, eas, ticks, mites, bedbugs,
wasps and bees cause problems by bites or
stings.
70
C H A P T E R
Immunologically
mediated skin disorders
71
Erythema multiforme
75
Erythema nodosum
77
Annular erythemas
77
77
Systemic sclerosis
80
Morphoea
82
Dermatomyositis
83
84
Blistering diseases
87
89
90
Pemphigus
91
Drug eruptions
92
Summary
95
This chapter describes several disorders with a strong immunopathogenic

component.

These common disorders are the result of histamine release from mast cells in
the skin.
CLINICAL FEATURES
Urticaria is extremely common (nettlerash, weals and hives are popular names
for this disorder) and there are few individuals who do not experience it in one
71
Immunologically mediated skin disorders
Figure 6.1 Urticarial lesions on the

back of a young man.
Figure 6.2 Marked swelling of the upper lip in

angioedema, which seemed to be due to sh
hypersensitivity in this patient.
form or another during their lifetime. Urticarial lesions are itchy, red papules
and plaques of variable size (Fig. 6.1) that arise suddenly, often within a few minutes, and last 624 hours. They may assume odd, polycyclic, annular and geographic forms.
An important characteristic of urticaria is its transience, but very occasionally
urticarial lesions stay for days rather than hours and leave a brownish stain. This
type of urticaria is due to involvement of small blood vessels and is known as urticarial vasculitis.
In many patients with urticaria and in a few people without it, rm pressure
over a track with a blunt object such as a key over the skin of the back will produce blanching, then redness, then a weal. This phenomenon, which is an exaggeration of the normal triple response, causes itching and is known as
dermographism.
In angioedema, the lesions are deeper and the swelling much more extensive
than in urticaria (Fig. 6.2). Angioedema may accompany urticaria or may occur
independently. The face and the tissues of the oropharynx are sometimes affected
by the angioedema, which can lead to life-threatening difculties in swallowing
and breathing.
Urticaria and angioedema can last for a few days or some years. A common
pattern is for the disorder to recur in a series of attacks. Chronic urticaria is a
common and sometimes disabling disorder, which in most cases is of unknown
origin.
72
Table 6.1 Some causes of urticaria

Sensitivity to exogenous antigens
Foods, e.g. sh, prawns, crabs, milk, etc.
Drugs, e.g. penicillin
Pharmacological provocation
Aspirin, opioids
Systemic disorders
Lupus erythematosus
HenochSchnlein purpura
Autoimmunity
Physical causes
Cholinergic urticaria
High pressure (dermographism)
Persistent pressure
Cold
Exposure to sunlight (solar)
Figure 6.3 Cold urticaria elicited by a block of ice.
CAUSES
The ultimate cause of urticaria and angioedema is release of histamine from mast
cell granules, but there is a large number of stimuli that can do this. Many are
immunological, some are purely pharmacological and others are physical. Type I
immunological reactions are involved in the production of urticarial lesions. Table
6.1 gives some of the known causes. Although the cause(s) of urticaria can be identied in some patients, in many it remains a mystery. In recent years it has been
found that some patients have antibodies to receptors on their own mast cells.
THE PHYSICAL URTICARIAS

Cold urticaria
Urticarial swelling of the hands, face and elsewhere may occur after exposure to the
cold. The reaction can be elicited by an ice block (Fig. 6.3). There is a familial form.
Pressure urticaria
Urticarial lesions develop some time (up to several hours) after pressure on the
skin, for example from belts or other tight clothing, or from the rungs of a ladder.
Dermographism
Many patients with urticaria mark easily when their skin is rubbed rmly, for
example with a key. This is an exaggerated triple response and is quite troublesome to some patients (Fig. 6.4).
73
Figure 6.4 Dermographic response to rm stroking

of the skin.
Figure 6.5 Solar urticaria. This patient was so

sensitive that he developed an urticarial response
to the minimal ultraviolet radiation of the A type
(long-wave UVA) emitted by a battery-driven, hand-held
uorescent lamp.
Solar urticaria
Urticarial spots develop on exposed skin a few minutes after exposure to the sun.
Various wavelengths may be responsible (Fig. 6.5).
CHOLINERGIC URTICARIA
Irritating, small urticarial spots develop after exercise or hot baths stimuli that
evoke sweating from the post-ganglionic cholinergically enervated sweat glands.
This very common disorder can be very disabling in a few patients, as it effectively
prevents them doing any kind of physical activity.
DRUG-INDUCED URTICARIA
Penicillin hypersensitivity is a common cause of urticaria. Attacks vary from the
life-threatening acute anaphylactic type to crops of small urticarial papules.
Opioid drugs can cause urticaria by directly stimulating histamine release. Up to
one-third of patients with urticaria develop lesions after challenge with aspirin,
but whether this is entirely due to pharmacological stimulation of histamine
release, involvement in prostanoid metabolism, or hypersensitivity is not certain.
STINGS
Nettles, jellysh tentacles and some insect stings elicit histamine release at the site
of skin contact, producing painful local reactions. Urticaria can also be a sign of
an underlying systemic disorder such as lupus erythematosus and amyloidosis
74
Erythema multiforme
and a component of disorders such as dermatitis herpetiformis (see page 89) and
allergic vasculitis (see page 84).
Treatment
Antihistamines of the H1 receptor blocker type are most effective at relieving

symptoms in this disorder. It is better to become really familiar with just a few of
these than to try to memorize the whole range available. The older antihistamines such as promethazine and diphenhydramine are quite effective, but have
a hypnotic effect precluding driving or using machinery. Newer antihistamines
such as foxfenadine, astemizole, cetirizine and loratidine are also effective, with
less hypnotic effect. A few patients obtain increased benet by adding an H2
antagonist such as cimetidine to the H1 antagonist already being administered.
Acute severe urticaria and angioedema may require oral corticosteroids. Where
the condition is life threatening, intravenous hydrocortisone should be used.
Erythema multiforme
DEFINITION
An acute and relatively short-lived inammatory reaction of skin and mucosae,
occurring in response to a variety of antigenic stimuli and resulting in scattered
lesions at the dermoepidermal junction.
CLINICAL FEATURES
Individual lesions are red to purple maculopapules, some of which become annular or target-like and may blister (Figs 6.6 and 6.7). The face and upper limbs are
preferentially involved, and the buccal mucosa is often involved in severely
affected patients. In the worst cases, there is severe systemic upset. The front of the
mouth is eroded in severely affected patients (Fig. 6.8). The conjunctivae and genital mucosae are affected in a few. The disorder starts acutely and usually lasts less
than 2 weeks, although crops of new lesions often develop in the rst few days.
Figure 6.6 Vesiculobullous lesions

of erythema multiforme. Some seem
target-like.
75
Figure 6.7 Widespread lesions of

erythema multiforme.
Figure 6.8 Eroded labial mucosa in

erythema multiforme. This patients
mouth was also affected.
AETIOLOGY AND PATHOLOGY

Table 6.2 Causes of
erythema multiforme
Drugs
Non-steroidal antiinammatory drugs
The disorder may be precipitated by infections, including herpes simplex, orf, coccidioidomycosis and histoplasmosis, drugs such as piroxicam, indomethacin and
other non-steroidal anti-inammatory compounds, sulphonamides and thiazide
diuretics (Table 6.2). In a proportion of patients, it recurs for no very obvious reason.
Mononuclear inammatory cells collect at the dermoepidermal junction and
uid collects beneath the epidermis.
Psychotropic drugs
Sulphonamides, other
antimicrobial drugs
Infections
Herpes simplex
TREATMENT
The disorder is self-limiting and only symptomatic treatment is required. Where
there is serious systemic disturbance, systemic steroids may be given.
Orf
Mycoplasma
Histoplasmosis
Coccidioidomycosis
Ultraviolet irradiation
Ulcerative colitis and
Crohns disease
Case 5
The condition started with soreness in the mouth. Sally, aged 27, thought that is
was the curry she had had the previous night. Within 2 days, she had developed
a widespread rash particularly over her arms and upper trunk. Many of the
lesions were annular and some showed blistering. The rash began to improve
after 12 days, but the disorder had made her feel tired and ill. It was thought to
be erythema multiforme in all likelihood precipitated by an attack of labial
herpes simplex some 2 weeks before the onset.
76
Erythema nodosum
DEFINITION
A painful inammatory disorder in which crops of tender nodules occur in
response to antigenic stimuli.
CLINICAL FEATURES
Individual lesions are red, raised and tender and vary in size from 1 to 3 cm in
diameter. They occur in crops on the shins (Fig. 6.9) and, less commonly, on the
forearms. There may be malaise, fever and an accompanying arthralgia of the
ankles. The lesions take 26 weeks to resolve and leave a bruised appearance.
Crops of lesions may develop over some months.
AETIOLOGY AND PATHOLOGY

There are numerous causes, including infections, drugs and systemic illnesses
(Table 6.3). The most important are sarcoidosis (see page 47) and pulmonary
tuberculosis. The disorder is also seen (rarely) in ulcerative colitis and leprosy.
A cause is identied in some 50 per cent of patients. It is essentially a panniculitis,
with inammation and bleeding occurring in the brous septa between fat lobules.
Figure 6.9 Multiple

inamed lesions of
erythema nodosum.
TREATMENT
Table 6.3 Causes of

erythema nodusum
Treatment is mainly rest and mild analgesics and/or anti-inammatory agents.
Tuberculosis
Sarcoidosis
Brucellosis
Annular erythemas
Ulcerative colitis and

Crohns disease
There are several disorders that are marked by the appearance of erythematous
rings, which usually gradually enlarge and then disappear. Generally their signicance is uncertain, but one, known as erythema gyratum repens, signies the
presence of an underlying visceral neoplasm (see page 281) and another, erythema chronicum migrans, indicates the presence of Lyme disease.
Leprosy
These disorders are also known as the collagen vascular disorders and the connective tissue diseases. In general terms, the immune system of an individual with
77
Figure 6.10 Facial erythema in a woman

with severe lupus erythematosus.
autoimmune disease fails to recognize the individuals own tissues and mounts
an attack on them. In most of the disorders in this group, the inammatory
process seems to involve the small blood vessels in particular (vasculitis).
LUPUS ERYTHEMATOSUS
This is divided into systemic and cutaneous forms, although there is some overlap.
Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) often involves the skin as well as many other
organ systems, but in one type of SLE subacute SLE the skin is prominently
affected. Antibodies to nuclear DNA occur in 8090 per cent of patients with SLE
and antibodies to other nuclear components are present in subgroups of patients.
These antinuclear factors may be intimately involved in the pathogenesis of the
disease.
Common components of SLE include a rheumatoid-like arthropathy, a
glomerulonephritis, inammatory disorder of the pulmonary and cardiovascular
systems, a polyserositis, central nervous system involvement and skin disorder.
The skin components of SLE include facial erythema across the cheeks and nose
(buttery erythema: Fig. 6.10), and discoid lupus erythematosus (DLE) occurs in
the pure cutaneous form.
Mainly young women are affected. The 5-year mortality has been variously
estimated to be between 15 and 50 per cent, dependent on the organ systems
affected and the pace of the disease.
78
Figure 6.11 Pathology of

a skin lesion in systemic
lupus erythematosus.
There are collections of
lymphocytes perivascularly.
Pathology and laboratory ndings

Affected skin shows oedema, degenerative change in the basal epidermal cells
and a tight cuff of mononuclear cells around the small blood vessels (Fig. 6.11).
Unexposed, uninvolved skin has deposits of immunoprotein immunoglobulin G
(IgG) or IgA in about 60 per cent of patients at the dermoepidermal junction,
detectable by direct immunouorescent methods. Circulating antibodies to DNA
or other nuclear components are found in the large majority of patients. An increase
in the level of serum gamma-globulin is a frequent nding. Haematological ndings include a normochromic, normocytic anaemia, a neutropenia, a lymphopenia and a thrombocytopenia.
Treatment
Patients with active, progressive disease may require systemic steroids to suppress
the inammatory process. Immunosuppressive agents such as methotrexate,
azathioprine and cyclosporin may also be needed.
Chronic discoid lupus erythematosus
Lesions of chronic discoid lupus erythematosus (CDLE) can occur in the

course of SLE or may be the only manifestation of the disorder. Frequently,
patients with CDLE have minor haematological changes of the sort described
in SLE, but no other features of SLE. In some 5 per cent of patients, CDLE
transforms to SLE.
Clinical features
Irregular, red plaques appear on light-exposed skin of the face, scalp, neck, hands
or arms (Fig. 6.12). The plaques develop patchy atrophy with patchy hypopigmentation and hyperpigmentation, whereas other areas are thickened and warty.
On the scalp, scarring alopecia occurs in the affected areas (Fig. 6.13). The disorder may be aggravated or initiated by exposure to the sun.
79
Figure 6.12 Multiple irregular, red

plaques due to discoid lupus
erythematosus.
Figure 6.13 Patch of discoid lupus

erythematosus causing alopecia.
Pathology
The changes are similar to those described for SLE, but the epidermal degenerative changes are more marked, with scattered cytoid body formation and patchy
epidermal atrophy and thickening.
Treatment
Sun avoidance and use of sunscreens are important. Individual lesions sometimes
respond to potent topical corticosteroids. Where these do not cope with the disease, hydroxychloroquine (200400 mg per day) is often helpful. Caution must
be exercised concerning the possible, although rare, toxic effects of this drug on
the retina. Systemic steroids, the oral gold compound auranon, cyclosporin and
acitretin are other drugs that have been used successfully.
Systemic sclerosis
Scleroderma is an important component of systemic sclerosis. In this autoimmune disorder, the broblast is stimulated to produce new collagen. When other
organ systems are involved, the disorder affects the vasculature as well as broblasts, and Raynauds phenomenon, renal involvement with glomerular disease,
gut involvement with dysphagia and gut hypomobility, a rheumatoid type of
80
Systemic sclerosis
polyarthropathy and skin stiffening are all seen (Table 6.4). As with SLE, the
disease is mostly seen in young women, and the pace of the disorder is extremely
variable. It may start insidiously over some months or even years, with progressively worsening Raynauds phenomenon and gradual thickening and stiffening of
the skin of the hands and face. This causes a characteristic beak-like facial appearance, with narrowing of the mouth (Fig. 6.14). Telangiectatic macules appear over
the face (Fig. 6.15) and deposits of calcium develop in the skin. The term CRST
syndrome is used for this constellation of problems (calcinosis cutis, Raynauds
sclerosis and telangiectasia). When there is also dysphagia due to oesophageal
involvement, the term CREST is more appropriate.
In more rapidly progressive systemic sclerosis, there may be more serious vascular disease affecting the ngers, resulting in tissue necrosis and even the loss of
portions of the digits. Renal or pulmonary disease may eventually cause the death
of the patient the 5-year mortality rate of this disease being 30 per cent or more.
PATHOLOGY AND LABORATORY FINDINGS
Table 6.4 Manifestations

of systemic sclerosis
Raynauds phenomenon
Skin thickening and
stiffness
Ischaemic necrosis
of digits
Dysphagia
Glomerulosclerosis and
renal insufciency
Hypertension
Malabsorption,
constipation
Pulmonary brosis
Biopsy of affected skin shows excess new collagen that has an eosinophilic and
almost homogeneous appearance. Antinuclear antibodies occur in up to 30 per cent
of patients.
Figure 6.14 Facial appearance in

systemic sclerosis. Note the beaked
nose with pinched cheeks and small
mouth.
Figure 6.15 Macular telangiectasia of

the facial skin in systemic sclerosis.
81
TREATMENT
There is no reliable way of signicantly modifying the disorder. Some improvement can be obtained by skilful management of the Raynauds phenomenon, and
occasionally with penicillamine and immunosuppressive treatment with steroids
and azathioprine or cyclosporin.
Morphoea
Morphoea is localized scleroderma.
CLINICAL FEATURES
One or more thickened, variably sized sclerotic plaques develop over the trunk or
limbs. A mauve colour at rst, they become brownish later (Fig. 6.16). It is mostly
a disease of young adults, but involvement of the face and scalp in children produces an en coup de sabre deformity. Morphoea generally gradually remits after
a period of 23 years. Histologically, there is marked replacement of the subcutaneous fat with new collagen, which has a pale, homogenized appearance. There is
no effective treatment.
Figure 6.16 Plaques of morphoea.

82
Dermatomyositis
VARIANTS
Generalized morphoea
This is a rare type of scleroderma that is conned to the skin but develops over
wide expanses of it, causing considerable limitation of movement and even
impeding breathing.
Lichen sclerosus et atrophicus
It is not certain whether or not this is a form of morphoea.

Small, irritating, whitish areas occur on the genitalia or around the anus or, less
commonly, elsewhere over the skin. In men, the condition occurs on the glans
penis or prepuce. It is then known as balanitis xerotica obliterans and may cause
discomfort and paraphimosis. There is a characteristic pathological picture in
which there is intense oedema in a subepidermal band.
Good results have been obtained with high-potency topical corticosteroids
(e.g. clobetasol 17-propionate). Circumcision is recommended for the condition
in men.
Dermatomyositis
Both muscle and skin are affected in this disabling disorder. Polymyositis is the
identical disorder without skin involvement.
CLINICAL FEATURES
Dull red to mauve areas develop over the face, backs of the hands, elbows, knees
and elsewhere. A particularly characteristic sign is the presence of a mauvish erythema on the upper lids and around the eyes, likened to the colour of the
heliotrope ower (Fig. 6.17). On the backs of the hands, the erythema affects the
paronychial folds and the skin over the metacarpals (Fig. 6.18).
Sometimes small areas of necrosis appear, due to an accompanying vasculitis.
Calcium is deposited in long-standing skin lesions.
There is proximal myositis, which causes pain and tenderness as well as profound weakness. If progressive, pharyngeal and respiratory muscles are affected
and the condition becomes life threatening. However, the disease generally remits
spontaneously.
LABORATORY FINDINGS
Muscle enzymes such as phosphocreatine kinase, aldolase and lactic dehydrogenase
are increased in the blood. Urine creatine is also a good indicator of disease activity. Muscle damage can also be assessed by muscle biopsy and electromyography.
83
Figure 6.17 Mauve discoloration of the facial skin in

dermatomyositis, with particular involvement of the
periocular area.
Figure 6.18 Streaky, mauve-red appearance over the

back of the metacarpals and ngers in dermatomyositis.
TREATMENT
Oral steroids are the mainstay of treatment and are given in sufcient dosage to
prevent further progress of the disease. Azathioprine and other immunosuppressive drugs are sometimes prescribed.

There are several disorders in which the major focus seems to be on the vasculature, with the kidneys, respiratory system, joints and skin apparently being primarily involved. The central nervous system and the gut are also involved on occasion.
ALLERGIC VASCULITIS (HENOCHSCHNLEIN PURPURA)

Although any age group can be affected, children and young adults seem especially prone to the disorder.
It starts suddenly, with fever, painful joints and a rash. The rash is both urticarial and papular, and particularly marked on extensor surfaces. It is also quite definitely purpuric in that it cannot be blanched by pressure with a microscope slide
(Fig. 6.19). The lesions come in recurrent crops over the rst few days.
84
Figure 6.19 Purpura in

HenochSchnlein
purpura.

allergic vasculitis.
Polymorphonuclear cells
and fragments of
polymorph nuclei are
seen around small
damaged blood vessels
(leucocytoclastic angiitis).
Joint pain with some swelling is quite commonly noted. Cramping abdominal
pain and malaena occasionally develop as a result of submucosal haemorrhagic
oedema. Acute glomerulonephritis causes microscopic haematuria when renal
involvement is mild, but oliguria and renal failure in a very few severely affected
patients. The disorder remits spontaneously in most patients, but may recur
in some.
Pathology and pathogenesis
The cause is unknown, but hypersensitivity to streptococcal antigens may play a

role in some patients. Immune complexes formed from streptococcal antigens and
antibodies are believed to be deposited in endothelium, initiating the reaction.
Histologically, collections of polymorphonuclear leucocytes and fragments of
their nuclei are found around small blood vessels in the dermis (leucocytoclasis)
alongside oedema and some bleeding. The endothelium is swollen and may show
degenerative change (Fig. 6.20). This picture, known as leucocytoclastic angiitis, is
not specic to this disease.
85
Treatment
Severely affected patients will need systemic steroids.
POLYARTERITIS NODOSA
Polyarteritis nodosa is a serious, rare inammatory disorder of large and
medium-sized arteries. Inammation of the vessel wall, which dilates aneurysmally,
causes rupture and ischaemic changes. Central nervous system, cardiovascular,
gastrointestinal and renal problems may all arise in this potentially fatal disease.
In the skin, a livedo reticularis pattern and persistent ulcers are seen.
NODULAR VASCULITIS
This is an uncommon inammatory disorder of the cutaneous vasculature of the
legs, seen predominantly in women.
Painful red and purpuric papules and nodules develop on the calves and elsewhere on the legs in recurrent crops over many years. Some may ulcerate, but
generally they disappear without sequel.
OTHER TYPES OF CUTANEOUS VASCULITIS

The development of crops of purple purpuric papules with darker and occasionally crusted central areas and sometimes pustules is seen in the course of subacute bacterial endocarditis, gonococcaemia and meningococcaemia (Fig. 6.21).
Drugs such as the thiazides may also cause a vasculitis. Renal involvement sometimes accompanies the skin lesions. The importance of such lesions is that they
are signs of an underlying systemic disorder demanding rapid diagnosis and
treatment.
Figure 6.21 Purpuric

and necrotic papules in
cutaneous vasculitis.
86
Blistering diseases
Figure 6.22 Pigmented and purpuric

eruptions due to Schambergs disease.
Figure 6.23 Patch with slight golden

hue due to purpura in lichen aureus.
CAPILLARITIS
There is a group of benign, persistent, mildly inammatory skin disorders in
which the focus of the abnormality appears to be in the papillary dermis and the
immediately subepidermal capillary vasculature. The term persistent pigmented
purpuric eruption seems appropriate, as they are persistent and because of
the damage to capillaries, causing leakage of blood and pigmentation from
haemosiderin staining. The lesions mostly occur on the lower legs and vary from
a macular, spattered appearance (Schambergs disease: Fig. 6.22) to an itchy, papular eruption (lichenoid purpuric eruption) or a macular golden eruption (lichen
aureus: Fig. 6.23). These disorders generally cause little disability and remit spontaneously after a variable period.
Blistering diseases
Many inammatory skin disorders can produce blistering at some stage in their
natural history. In the primary blistering diseases, blistering is the major feature
of the disease and a direct result of the initial pathological process. The different
blistering diseases are given in Table 6.5.
87
Table 6.5 The primary blistering disorders

Subepidermal
Senile pemphigoid
Acute, widespread, severe
Cicatricial pemphigoid
Chronic, limited in extent, mucosae affected causing

erosion and scarring
Erythema multiforme
Acute, mucosae as well, variously caused
Itchy, persistent, associated with gluten enteropathy
Genetically and phenotypically diverse, varies from

mild to lethal
Intraepidermal
Pemphigus
vulgaris
vegetans
erythematosus
foliaceous
Suprabasal epidermal split

Subcorneal epidermal split
SUBEPIDERMAL BLISTERING DISEASES

Bullous pemphigoid (senile pemphigoid)
Bullous pemphigoid (BP) is an uncommon, acute blistering disease occurring

mainly in the over-60s.
Large, tense, often blood-stained blisters develop over a few days anywhere
on the skin surface (Fig. 6.24) except the buccal mucosa. New crops of blisters continue to appear for many months without adequate treatment, and the disease is
painful and disabling. Rarely, the disorder is a sign of an underlying malignancy.
Laboratory ndings
There is a circulating antibody directed to the epidermal basement membrane
zone in 8590 per cent of patients, which can be detected using the immunouorescence method. The titre of this antibody is to some extent a reection of the
activity of the disease. Antibodies of the IgG type and the complement component C3 are also deposited in the subepidermal zone around the lesions in the
majority of patients and can also be detected using the direct immunouorescence technique (Fig. 6.25). Biopsy reveals that there is subepidermal uid, with
polymorphs and eosinophils in the inltrate subepidermally (Fig. 6.26).
Figure 6.24 Tense blisters
due to bullous pemphigoid.
Treatment
Patients with widespread blistering may need to be nursed in hospital and treated
as though they had severe burns. High doses of corticosteroids (60 mg per day of
prednisone, or even more) are needed to control the disease. Immunosuppressive
treatment with azathioprine or methotrexate is usually started simultaneously. The
blisters themselves should be treated with wet dressings.
88
Figure 6.25 There is a uorescent band at the

dermoepidermal junction in this uorescence
photomicrograph due to deposition of immunoglobulin
(IgG). A biopsy from the skin around the site of blistering
was frozen and the cryostat section treated with
uorescein-tagged anti-immunoglobulin antibodies.
Figure 6.26 Pathology of bullous pemphigoid showing

subepidermal blister.
Variants of bullous pemphigoid

There are other rare blistering diseases in which the blister forms subepidermally.
These include:
benign mucous membrane pemphigoid, in which lesions occur chronically in

the mouth and in the conjunctivae as well as on the skin
bullous disease of childhood, in which bullous lesions occur in infancy, particularly in the buttock and perigenital area.
In the latter disorder, and in some blistering conditions in adults, IgA is deposited instead of IgG.
Intensely itchy vesicles, papulovesicles and urticarial papules appear in crops over
the knees, elbows, scalp, buttocks and around the axillae (Fig. 6.27). Most patients
with dermatitis herpetiformis (DH) have a mild gastrointestinal absorptive defect
due to gluten enteropathy, as in patients with coeliac disease. Some diseases with
an immunopathogenetic component are more common in patients with DH,
including thyrotoxicosis, rheumatoid arthritis, myasthenia gravis and ulcerative
colitis. The disorder is persistent but uctuates in intensity.
LABORATORY FINDINGS
Small-bowel mucosal biopsy reveals partial villous atrophy in 7080 per cent of
patients with DH. Minor abnormalities of small-bowel absorptive function are
Figure 6.27
Vesiculopapules in
dermatitis herpetiformis.
89
Figure 6.28 Pathology of dermatitis herpetiformis. There are collections of polymorphs

in the tips of the dermal papillae where the subepidermal blistering begins.
also common. Biopsy of new lesions demonstrates that the vesicle forms subepidermally and develops from collections of inammatory cells in the papillary tips
(the papillary tip abscess: Fig. 6.28). Direct immunouorescent examination
reveals the presence of IgA in the papillary tips in the skin around the lesions in
all patients.
TREATMENT
The skin lesions can be suppressed with the drug dapsone (50200 mg per day)
in most patients. Unfortunately, however, dapsone has many toxic side effects,
including haemolysis, methaemoglobinaemia, sulphaemoglobinaemia and rashes
such as xed drug eruption. A gluten-free diet will improve the gastrointestinal
lesion and improves the skin disorder in many patients after some months.
This is not a single disorder, but a group of similar, inherited blistering diseases.
The blistering is caused by various congenital structural and metabolic defects.
EPIDERMOLYSIS BULLOSA SIMPLEX

The blistering in this rare disorder appears subepidermal, but is actually through
the basal layer of the epidermis. It is usually limited to the hands and feet and the
sites of trauma. It is dominantly inherited. The blisters may just be conned to the
90
Pemphigus
soles of the feet and not prove troublesome until adolescence. As with most genodermatoses, these conditions persist throughout life. There is no effective treatment other than to avoid trauma and to keep the blistered areas clean and dry.
DYSTROPHIC EPIDERMOLYSIS BULLOSA

Disorders in this rare group of conditions cause severe scarring and indeed some
forms are not compatible with life. They are also subepidermal, but the split is within
the upper dermis. They are mostly recessive, but there are some dominant types too.
Blistering and scarring cause marked tissue loss over the hands and feet, with eventual webbing of the ngers and toes and possibly loss of these structures. There is
also marked scarring of the mucosae, which affects the pharynx and oesophagus
too, so that severe dysphagia is a problem. Squamous cell carcinoma develops on
the most severely affected sites in some patients. This is a terrifyingly destructive and
disabling group of disorders for which there is at present no adequate treatment.
Pemphigus
Pemphigus causes blistering because of a loosening of desmosomal links between
epidermal cells caused by immunological attack. There are several types. They are
all rare, but pemphigus vulgaris (PV) is the least rare. In PV, the split occurs within
the epidermis just above the basal layer (suprabasal). The lesions are thin-walled,
delicate blisters that usually rapidly rupture and erode (Fig. 6.29). They occur anywhere on the skin surface and very frequently occur within the mouth and throat,
where they cause much discomfort and disability. The disorder is persistent,
although uctuating in intensity. Before adequate treatment became available, it
was usually fatal.
Figure 6.29 Eroded area on the face

due to pemphigus vulgaris.
91
LABORATORY FINDINGS
In more than 90 per cent of patients, there is a detectable circulating antibody
directed to the area between epidermal cells. The titre of the antibody reects the
severity of the disease. The presence of the antibody and its titre are determined
by indirect immunouorescence methods. Biopsy reveals the intraepidermal split,
with rounded up epidermal cells (known as acantholysis). Direct immunouorescence examination of the perilesional involved skin will show the presence of antibody of the IgG class and the complement component C3 between epidermal cells.
TREATMENT
The patients should be treated as though they had burns and, if severely affected,
need in-patient care. Large doses of systemic steroids are required to control the
blistering (doses of up to 100 mg prednisone are sometimes given). Immunosuppressive therapy with azathioprine or methotrexate should be started simultaneously. Treatment with cyclosporin and with gold, as for rheumatoid arthritis,
has also been used.
VARIANTS
Pemphigus vegetans
There is a more inammatory component to this very rare intraepidermal

blistering condition in which the lesions are usually limited in extent.
Pemphigus foliaceous
This is a rare form of pemphigus in which the intraepidermal split is high within
the epidermis. It can cause erosions and scaling rather than blistering and can be
mistaken for sebborrhoeic dermatitis.
Pemphigus erythematodes
This rare, supercial type of pemphigus lesions have some resemblances to

discoid lupus erythematosus. It occurs around the face and scalp particularly.
Drug eruptions
Most drugs have side effects as well as pharmacological effects, and skin disorders
are a frequent form of drug side effect. These can mimic many of the spontaneously occurring skin disorders as well as producing quite specic changes.
Drug-induced skin disorder can develop after the initial dose or after a short
period of time during which sensitization has taken place. Other problems, such
as pigmentations or hair anomalies, may take some months to appear. Often, a
rash occurs after taking the drug for some time, without apparent reason.
92
Drug eruptions
It is important that drug reactions are suspected when the nature and cause
of a skin disorder are in doubt, as drugs in one shape or form are taken by a
substantial proportion of the population. Drug eruptions do not only stem from
orthodox prescribed drugs, but are also caused by cough medicines, analgesics,
laxatives or other over-the-counter symptomatic remedies, and enquiry must
also be made about these possibilities.
The diagnosis of a drug eruption is difcult to conrm, as there are few laboratory tests available. Currently, the only useful specic laboratory tests are those
dependent on there being specic IgE directed to the particular drug penicillin
is the only drug of importance that can be detected in this way (radio allergoabsorbent test, RAST).
Skin biopsy may assist in eliminating other causes of an eruption. The most
useful diagnostic test is the challenge, in which the suspected agent is administered to determine whether the condition recurs or is aggravated. Clearly, this is
not possible in the case of potentially severe or life-threatening conditions. Even
when this is not the case, it should only be performed with the patients consent
and if important information may be obtained that is relevant to the care of the
patient. The smallest possible dose should be given and the patient should be carefully observed subsequently.
TYPES OF DRUG ERUPTION

Severe life-threatening eruptions
Angioedema and anaphylactic shock

These are sudden in onset and IgE-mediated reactions of the immediate hypersensitivity type. They are provoked by serum-containing products and by penicillin and its derivatives when given parenterally. The patient becomes pale and
collapses with severe hypotension and maybe bronchospasm. Treatment is
required urgently with oxygen, intravenous hydrocortisone and adrenalin.
Erythema multiforme (StevensJohnson syndrome)
For a clinical description, see page 75. Sulphonamides, hydantoinates, carbamazepine, some non-steroidal anti-inammatory agents and maybe penicillin can
cause this disorder.
Toxic epidermal necrolysis
This drug reaction, which has a mortality approaching 50 per cent, occurs predominantly in middle-aged and elderly women. The drugs incriminated include
sulphonamides, indomethacin, the hydantoinates and gold salts. There is erythroderma with extensive desquamation and, in places, blistering and erosion. The
mucosae are also severely affected.
The patients rapidly become dehydrated and are very sick. They need to be
nursed as though they had extensive burns and to have intensive support treatment with parenteral uids, antibiotics and systemic steroids.
93
Exanthematic eruptions
This is probably the commonest group of drug eruptions. Red/pink macules

develop over the trunk and limbs. When intense, the rash is said to be morbilliform or measles-like. Ampicillin, the psychotropic drugs and the non-steroidal
anti-inammatory agents cause this type of rash.
A lichenoid rash (with some resemblance to lichen planus, see page 144) may
be caused by gold salts, mepacrine and carbamazepine.
Vascular eruption or purpuric lesions develop over the legs and, less frequently,
the arms and trunk. The thiazide diuretics and the hydantoinates are especially
linked with this type of rash.
Urticarial rashes may be produced by penicillin, aspirin, tartrazine (and other
dyes) and opioid drugs.
PHOTOSENSITIVITY RASHES
In this group of drug-induced conditions, the rash is conned to the lightexposed areas and is wavelength dependent, i.e. it only reacts to particular wavelengths in the solar ultraviolet spectrum. The rash itself is red and papular or
plaque-like (Fig. 6.30). Some drugs seem able to provoke a phototoxic eruption,
which is seen in many patients to whom the drug is given and is dose dependent,
and others cause a photoallergic rash in which a photoallergen has formed and
which only affects a few individuals. Tetracyclines and sulphonamides may cause
a phototoxic response. The phenothiazines may cause either a phototoxic or a
photoallergic reaction.
Blistering rashes
Naproxen and frusemide may cause a pseudoporphyria-like rash in the lightexposed sites. Nalidixic acid may also cause blistering. Captopril and penicillamine may cause a pemphigus or a pemphigoid-like eruption.
Figure 6.30 Photosensitivity rash due to

the administration of a tetracycline drug.
94
Summary
Fixed drug eruptions
This not uncommon drug reaction causes inammatory patches to appear within
hours at the same sites on every occasion the drug is administered. The areas
become inamed, and may even blister before subsiding when the drug is
stopped, leaving pigmentation (Fig. 6.31). Numerous drugs, including dapsone,
the sulphonamides, tetracycline and mefenamic acid may be responsible.
Lupus erythematosus-like rashes
These may be caused by penicillamine, hydralazine, hydantoinates and procainamide,

amongst others. The drugs may precipitate or initiate lupus erythematosus.
As pointed out elsewhere, drugs can have many other effects on the skin,
including changes in pigmentation and hair distribution.
TREATMENT
Figure 6.31 Round, dusky

erythematous patch on the
buttock due to xed drug
eruption caused by
mefenamic acid.
Treatment of all drug eruptions consists of identifying the causative drug and
then stopping it. Care must be taken to see that the offending agent or one with
cross-reacting chemical groups is not given again.
Summary
Urticaria and angioedema result from histamine
release from mast cells and are characterized by
transient, itchy weals or deeper swellings.
Dermographic weals are elicited by rm stroking
with a blunt object.
The cause of chronic urticaria remains
undiscovered in most patients, but in a few food
hypersensitivities, drug sensitivity and physical
stimuli are found to be responsible. In a
substantial minority, an antibody to mast cells
has been found, so that the disorder can
be thought of as autoimmune. In cholinergic
urticaria, small, itchy weals occur after exercise
or hot baths.
Antihistamines of the H1 type are the most
effective in suppressing urticaria.
Erythema multiforme is caused by infections such
as herpes simplex and orf, as well as by drugs and
systemic diseases. It is an acute exanthematic
disorder, characterized by maculopapular lesions,
some of which are annular and may blister. The
mucosae are often affected.
Erythema nodosum is characterized by the sudden

appearance of large, tender, red nodules on the
shins, mostly with arthralgia and systemic upset. It
is a reaction to tuberculosis, sarcoidosis and, less
commonly, other infections and drugs.
Systemic lupus erythematosus is characterized by
facial (buttery) erythema, arthritis,
glomerulonephritis, other visceral inammatory
disorders and circulating antinuclear factor
antibodies. Histologically, degeneration of the basal
layer of the epidermis and perivascular lymphocytic
cufng are typical.
Chronic discoid lupus erythematosus occurs in the
course of systemic lupus erythematosus or without
other signs and is characterized by irregular red
plaques in which atrophic scarring and irregular
pigmentation are seen. Sun protection,
hydroxychloroquine and potent steroids are used in
treatment.
In systemic sclerosis, Raynauds phenomenon, renal
glomerular disease, arthritis, gut disorder and skin
stiffening of the face and hands result from the
95
production of excess new collagen. Raynauds

phenomenon and dysphagia are common problems.
In morphoea, single or several mauve, indurated
plaques are the sole manifestation of scleroderma.
In lichen sclerosis et atrophicus, small, white
patches occur over the genitalia and, less
frequently, elsewhere.
Proximal muscle tenderness and weakness
accompany mauve red patches on the backs of the
hands and periocularly in dermatomyositis.
Allergic vasculitis causes fever, arthralgia and an
urticarial purpuric rash. Abdominal pain, melaena
and glomerulonephritis are also found. Endothelial
damage and neutrophilic nuclear dust are seen
histologically.
Polyarteriitis nodosa, nodular vasculitis
and vasculitis accompanying meningococcaemia
and gonococcaemia are other types of
vasculitis.
Persistent, pigmented purpuric eruptions are
caused by a capillaritis.
Subepidermal blisters in senile pemphigoid are

caused by circulating anti-basement membrane
antibodies. Treatment is with high doses of
corticosteroids and immunosuppressive agents.
Cicatrical pemphigoid and bullous disease of
childhood are variants.
Dermatitis herpetiformis is an itchy vesicular
disease, in which subepidermal blisters and
papillary tip abscesses occur accompanied by a
gluten enteropathy. Dapsone controls the skin
lesions.
Epidermolysis bullosa is a group of inherited,
subepidermal blistering disorders, which can
cripple and deform in the worst cases.
Intraepidermal blistering caused by circulating
antibodies to the epidermal desmosomal junctions
characterizes the pemphigus group of diseases.
Drugs can cause urticarial, erythema multiformelike, exanthematic rashes. Photosensitivity, lupus
erythematosus-like and xed drug eruptions are
other cutaneous adverse drug reactions.
96
C H A P T E R
Skin disorders in AIDS,

immunodeciency and
venereal disease
Infections
98
Skin cancers
99
99
Psoriasis
100
100
100
101
101
102
Summary
104
Acquired immune deciency syndrome (AIDS) is caused by a lymphotropic

retrovirus, now known as the human immunodeciency virus (HIV). The virus
is acquired either by sexual intercourse (homosexual or heterosexual) or from the
accidental introduction of material contaminated by the HIV into the systemic
circulation. It was most common in homosexuals, drug addicts and the recipients
of contaminated blood in the form of transfusions or concentrates, but is now
spreading via heterosexual contact. The virus incapacitates the T-helper lymphocytes and thus prevents proper functioning of the cell-mediated immune response.
It uses the T4 antigen as its receptor and employs the T-cells genomic apparatus
to replicate, destroying the cell as it does so. It can also infect reticuloendothelial
cells (including Langerhans cells) and B-cell lymphocytes.
After gaining access, the virus usually stays latent for long periods, but may
cause a systemic illness a relatively short time after infection and before or at the
time of seroconversion. This illness is characterized by pyrexia, malaise and a rash,
which have been described as resembling infectious mononucleosis.
For the most part, there are no symptoms for several years, even after an antibody
response develops, until the virus is activated by an intercurrent infection such as
herpes simplex. AIDS is characterized by depressed delayed hypersensitivity, and
depressing of the number of circulating T-helper cells is a constant nding. Skin
disorders are prominent in AIDS and patients often present with a skin complaint.
97
Skin disorders in AIDS, immunodeciency and venereal disease
Infections
When the disease is activated, the patient becomes subject to opportunist infections as well as to an increased incidence and severity of usually mild and commonplace infections.
FUNGUS INFECTIONS
Dermatophyte infections, including nail infection, are extensive and difcult to
clear. Candidiasis is often a major problem, especially in the mouth and oropharynx. Systemic spread of Candida infection is unfortunately not uncommon and
often a terminal event. Pityrosporum ovale causes extensive eruptions of pityriasis
versicolor. It may also be responsible for a troublesome and persistent truncal folliculitis in some patients (Fig. 7.1) and for the common problem of severe seborrhoeic dermatitis seen in others. Various deep fungus infections are common,
particularly in hot and humid parts of the world.
VIRAL INFECTIONS
Viral warts may become very extensive and troublesome. Mollusca contagiosa
lesions may be both larger than usual and present in very large numbers (Fig. 7.2).
Figure 7.1 Folliculitis due to

Pityrosporum ovale infection in a patient
with HIV infection.
Figure 7.2 Mollusca contagiosa

multiple lesions in a patient with
advanced AIDS.
98
Herpes simplex infection may be a particular problem, with extensive and persistent skin involvement resulting in scarring. Herpes zoster is similarly a troublesome infection in AIDS and may be the initial manifestation. It may look unlike
ordinary herpes zoster and may cause considerable pain and tissue destruction
as well as spreading outside the dermatomes in which it began.
BACTERIAL INFECTIONS
Tuberculosis and syphilis are both major problems for individuals with AIDS.
Both disorders progress rapidly and are responsible for extensive and severe disease in AIDS patients. Infections with mycobacterial species that do not generally
infect humans may also be seen. Epithelioid angiomatosis is due to infection with
a bacterial micro-organism similar to the bacillus causing cat scratch disease. It
causes Kaposis sarcoma-like lesions (see below) and a widespread eruption of red
papules.
Skin cancers
Depressed delayed hypersensitivity also results in failure of immune surveillance
and the development and rapid progression of many forms of skin cancer. Viral
infection may also be at work in the development of the disorder known as
Kaposis sarcoma, which mainly accompanies AIDS contracted from homosexual
contact. Mauve, red, purple or brown macules, nodules or plaques may ulcerate
and may spread to involve the viscera. Kaposis sarcoma is a frequent cause of
death in patients with AIDS.
Case 6
Simons dandruff gradually worsened and he developed seborrhoeic dermatitis of
the skin around his ears and nose. At the age of 23, he was surprised that he
was also developing numerous viral warts and mollusca contagiosa. His partner,
Peter, thought that they should both have tests for HIV disease and both men
were found to be positive.

PRURITUS
The papular folliculitis rash mentioned above due to Pityrosporum ovale is often
distressingly pruritic. The skin of patients with AIDS may become dry and ichthyotic looking, so that AIDS may be counted as one of the causes of acquired
ichthyosis, and this is also a cause of persistent irritation.
99
SCABIES
Scabies seems to spread very quickly and to cause extensive and severe involvement
in patients with AIDS. It also causes severe itching.
SEBORRHOEIC DERMATITIS
Another cause of itching in AIDS is seborrhoeic dermatitis. This is common
and extensive in patients with AIDS, presumably due to massive overgrowth of
Pityrosporum ovale and whatever other micro-organisms are involved (Fig. 7.3).
Psoriasis
Figure 7.3 Extensive orid

seborrhoeic dermatitis in a
patient with HIV infection.
Pre-existing psoriasis may develop an explosive phase, or psoriasis may develop

de novo as an aggressive, rapidly spreading eruption. It is not clear why psoriasis
is aggravated in this manner in HIV infection.

Treatment with zidovudine (azidothymidine, AZT) 5001500 mg per day in four
to ve divided doses is indicated to slow the progress of the HIV infection. It causes
nausea, malaise, headache, rash and many other side effects. Zidovudine is a reverse
transcriptase inhibitor. Other drugs that are sometimes used include lamivudine,
nevirapine, stavudine, delavudine and efavirenz.
Ganciclovir and foscarnet are indicated for cytomegalovirus complications.
Aciclovir is used for herpes simplex and herpes zoster. Various antibiotics and
other antimicrobials are used as indicated for the bacterial infections. Fluconazole,
itraconazole and ketoconazole are particularly useful for the serious and lifethreatening Candida infections. Recombinant interferon-alpha 2B and other interferons have been used with some success in Kaposis sarcoma. The new retinoid
tagretin is used topically to induce regression in individual lesions.
Patients who have organ transplants of kidneys, heart or liver are maintained on
corticosteroids and azathioprine, cyclosporin or tacrolimus for the rest of their
lives. Patients with autoimmune disorders such as systemic lupus erythematosus,
rheumatoid arthritis or chronic renal disease, and those with psoriasis and some
eczematous diseases, are also treated with immunosuppressive drugs for varying
lengths of time. The cutaneous side effects from the immunosuppression are not
usually as prominent as in AIDS patients, but depend on the extent and length of
the immunosuppression.
100
Figure 7.4 Warty lesions

on the hands in a patient
after 8 years on
azathioprine and
prednisolone following
renal allograft, which
are either viral warts or
solar keratoses, or
somewhere in between.
Patients with renal allografts have most problems, maybe because they are treated
continuously for longer periods than most of the other groups. They are prone to
the development of numerous warty lesions on the hands and face after about
8 years of immunosuppression some 25 per cent were found to have warty lesions
in one British study (Fig. 7.4). These are either viral warts or solar keratoses, or
lesions which are somewhere in between! It may be that many of the viral warts
directly transform into pre-neoplastic lesions.
It should be noted that photochemotherapy with ultraviolet radiation of the
A type (PUVA) treatment (see page 141) also causes depression in delayed hypersensitivity and this is probably relevant to the development of skin cancer in
patients with psoriasis treated with PUVA some years previously.

Lymphoreticular diseases such as Hodgkins disease, the leukaemias and sarcoidosis
also result in depressed delayed hypersensitivity. Hypovitaminosis A, chronic malnutrition and chronic alcoholism also result in depressed immune defences.
Infantile agammaglobulinaemia is inherited as an X-linked recessive disorder.
There are no plasma cells in the marrow and the patients are susceptible to severe
pyoderma and numerous warts. In severe combined immunodeciency, there is
depression of circulating lymphocytes and levels of all immunoglobulins. Patients
are susceptible to all infections and usually die between the ages of 1 and 2 years. It
is inherited as either a sex-linked recessive or an autosomal recessive characteristic.
Ataxia telangiectasia (autosomal recessive) is characterized by cerebellar degeneration, telangiectasia on exposed skin developing progressively, lymphopenia and
depressed levels of IgA.
101

Several skin infections, although not exclusively venereal, are nonetheless spread
by venereal contact. Such disorders include genital warts, molluscum contagiosum, scabies and pubic lice.
REITERS SYNDROME
This disorder occurs as a sequel to non-specic urethritis in men and, less commonly, to bowel infection, and probably results from infection with a Mycoplasma
organism. There is usually an accompanying arthritis and spondylitis and occasionally a conjunctivitis. Psoriasiform skin lesions develop on the soles and toes. These
are often severe, persistent, aggressive and pustular (keratoderma blenorrhagica).
Inamed, red, scaling patches may also develop on the glans penis (circinate balanitis). There is a curious preponderance of patients with the HLA B27 haplotype.
GONORRHOEA
This venereal disease, which predominantly affects urethral epithelium, is caused
by the delicate intracellular Gram-positive diplococcus the gonococcus. The
skin is only affected during gonococcaemia, when small purpuric and pustular
vasculitic lesions suddenly appear in the course of a pyrexal illness (Fig. 7.5).
CHANCROID (SOFT SORE)

This venereal infection is caused by the Gram-negative bacillus Haemophilus ducreyi.
One to 5 days post-infection, a soft sloughy ulcer appears on the penis or vulva.
Other sites may be affected, and inguinal adenitis occurs in 50 per cent of patients.
Differential diagnosis includes syphilitic chancre, herpetic ulceration, granuloma inguinale and the results of trauma. The treatment of choice is erythromycin (500 mg 6-hourly for 14 days).
Figure 7.5 Vasculitis.

102
SYPHILIS
Syphilis has once again become of major importance with the emergence of AIDS.
This is both because the syphilitic chancre serves as a portal of entry for the HIV
virus and because the manifestations of syphilis are much more dramatic in AIDS
patients.
The disease is caused by the delicate spirochaetal micro-organism Treponema
pallidum, which is transmitted by contact between mucosal surfaces.
Clinical features
Characteristically, the incubation period is 990 days and the rst sign is the
appearance of the chancre at the site of inoculation, usually on the glans penis,
prepuce or, less often, on the shaft in men and on the vulva in women. In homosexuals the chancre appears around or in the anus. The chancre is of variable size
(0.53 cm in diameter) and has a sloughy and markedly indurated base. Untreated,
it heals after 38 weeks.
This primary stage of the disease is followed by a brief quiescent phase of from
2 months to up to 3 years before the secondary stage occurs. In secondary syphilis
there are signs of systemic upset with mild fever, headache, mild arthralgia, generalized lymphadenopathy and skin manifestations, including an early widespread
macular rash, involving the palms (Fig. 7.6), and a later papular or lichenoid eruption. Thickened, warty areas (condylomalata) appear perianally and in other moist
exural sites (Fig. 7.7). Ulcers appear on the oral mucosa (snail-trail ulcers).
Figure 7.6 Palmar rash in secondary

syphilis.
Figure 7.7 Perianal condylomata in

secondary syphilis.
103
After resolution of the secondary stage, there is a latent period without signs or
symptoms, lasting for 550 years. The tertiary stage takes protean forms and
includes cardiovascular disease with aneurysm formation, central nervous disorder, either as tabes dorsalis or general paralysis of the insane, and ulcerative or
gummatous lesions that may occur on the skin or on mucosal surfaces.
Diagnosis
Diagnosis is made by identication of the spirochaete from wet preparations of the

chancre or moist secondary-stage lesions and by serological tests detecting either
lipoidal substance liberated by tissues or the presence of antibodies to the microorganism.
The older Wassermann reaction (WR) has been replaced by the Venereal Disease
Reference Laboratory (VDRL) test, which is a occulation test, which, although not
specic, is quite sensitive and becomes positive early in the disease. It also responds
to effective treatment by becoming negative some 6 months after therapy. The
WR and the VDRL tests (and other similar tests) depend on lipoidal antigens. The
Treponema pallidum haemagglutination assay is currently the most-used specic
test depending on antibodies to the micro-organism.
TREATMENT
The treatment of syphilis is by parenteral penicillin over a 10-day period. One intramuscular injection of procaine penicillin 600 000 IU daily for 10 consecutive days is
adequate. A proportion of patients develop a fever and possibly a rash after starting
treatment (JarischHerxheimer reaction). More serious reactions can also occur.
Summary
AIDS is caused by a retrovirus the Human Immunodeciency Virus (HIV), which is transmitted by
sexual contact. It is characterized by depressed
delayed hypersensitivity and susceptibility to many
skin infections, including candidiasis, pityriasis
versicolor, molluscum contagiosum, warts, herpes
simplex, herpes zoster as well as tuberculosis and
syphilis. Seborrhoeic dermatitis, pruritic folliculitis
and Kaposis sarcoma are other skin disorders
occurring in AIDS. Steroids and immunosuppressive
drugs result in immunosuppression, and depressed
delayed hypersensitivity is also seen in Hodgkins
disease, vitamin A deciency and after UVR
exposure. In some cases, immunodeciency is
inherited.
Reiters syndrome follows non-specic urethritis. Thick

psoriasiform lesions occur on the feet and genitalia.
Purpuric pustules are a vasculitic complication of
gonorrhoea and gonococcaemia.
Chancroid (soft sore) caused by Haemophilus
ducreyi is characterized by soft erosions occurring
on the genitalia.
Syphilis caused by Treponema pallidum is spread by
sexual contact. Nine to 90 days post-infection, an
erosion, the primary chancre, occurs at the site of
inoculation. A secondary stage with rashes and mild
systemic upset develops some weeks or months
later. After a latent period, a tertiary stage develops
in which a destructive inammation affects one or
another organs. Treatment is with penicillin.
104
C H A P T E R
Eczema
(dermatitis)
Atopic dermatitis
105
114
117
118
119
Contact dermatitis
121
125
Summary
126
The term eczema includes several disorders (see Table 8.1) in which inammation
is focused on the epidermis. Typically, epidermal cells accumulate oedema uid
between them (spongiosis: Fig. 8.1), leading to vesicles in the most severe and
acute cases. Inammatory cells and vasodilatation accompany the oedema that is
also present in the dermis of the affected area.
Some types of eczema stem from uncharacterized constitutional factors
(endogenous or constitutional eczema), whereas others are the result of an external injury of some sort. The clinical picture varies according to the provocation,
the acuity of the process and the site of the involvement.
Atopic dermatitis
DEFINITION
This is a very common, extremely itchy disorder of unknown cause that characteristically, but not invariably, affects the face and exures of infants, children,
adolescents and young adults.
105
Eczema (dermatitis)
Table 8.1 Common types of eczema

Type
Synonyms
Frequency/age group
Remarks
Atopic dermatitis
Neurodermatitis
Besniers prurigo
Infantile eczema
Very common, mostly

occurs in infants and
the very young
Cause unknown, but appears

to be immunologically mediated
Seborrhoeic
dermatitis
Infectious eczematoid
dermatitis
Very common in all

age groups
Probably has a microbial cause,

with overgrowth of normal skin
ora being responsible
Discoid eczema
Nummular eczema
Uncommon, mainly in
middle-aged individuals
Cause unknown
Lichen simplex
chronicus
Circumscribed
neurodermatitis
Quite common, mainly in

young and middle-aged
adults
Initial cause appears to be a

localized itch causing an
itchscratch cycle
Eczema craquele
Asteatotic eczema
Uncommon, restricted
to the elderly
Low humidity and vigorous

washing seem responsible
Venous eczema
Stasis dermatitis
Gravitational eczema
Common in the age group

that has gravitational
syndrome
Multiple causes, a common

variety is allergic contact
dermatitis to medicaments
used
Common in all adult age

groups except the very old
Delayed hypersensitivity
response to a specic agent
Very common in all adult

age groups except the
very elderly
Both mechanical and chemical

trauma responsible
Not uncommon,
mainly in adults
Both phototoxic and

photoallergic types occur
Allergic contact
dermatitis
Primary irritant
contact dermatitis
Photosensitivity
eczema
Occupational dermatitis
Housewives eczema
Figure 8.1 Photomicrograph to

show an area of oedema of the
epidermis (spongiosis) in acute
eczema (H & E, 90).
106
Atopic dermatitis
Figure 8.2 Inamed, thickened eyelids and some loss

of eyebrows and eyelashes due to perpetual eye rubbing
in atopic dermatitis.
(a)
(b)
Figure 8.3 (a) Excoriations of the wrists in atopic dermatitis. (b) Excoriated, thickened eczematous area over the
sacrum.
CLINICAL FEATURES
Signs and symptoms
The major issue as far as this disease is concerned is itching. The patient is constantly
itchy and restless, but subject to irregular episodes of intense and quite disabling
intensication of the pruritus. The itchiness is made worse by changes in temperature, by rough clothing (such as woollens) and by sundry other minor environmental alterations. This symptom greatly disturbs sleep and the whole family
becomes affected. Scratching results from the severe pruritus in all except infants
under the age of 2 months. Patients also rub the affected itching parts they
frequently rub their eyes with the index nger knuckles (Fig. 8.2). The incessant
scratching and rubbing result in simple, linear scratch marks (excoriations:
Fig. 8.3) and chronic thickening of the skin characterized by accentuation of the
skin markings known as lichenication (Fig. 8.4). This is due to massive epidermal hypertrophy as well as oedema and inammatory cell inltrate in the
upper dermis (Fig. 8.5).
Figure 8.4 Exaggeration of

skin surface marking
(lichenication) due to
perpetual rubbing and
scratching.
107
Eczema (dermatitis)
Figure 8.5 Photomicrograph showing marked

epidermal thickening and inammation in lichenication
(H & E, 45).
Figure 8.6 Prominent skin surface markings of the

palms (hyperlinear palms) in atopic dermatitis.
Figure 8.7 Eczema of the face in an
infant.
Figure 8.8 Excoriated lichenied

popliteal fossae in atopic dermatitis.
In many patients, there is a widespread ne scaling of the skin, described as

dryness or xeroderma, sometimes described incorrectly as ichthyosis, but really
the result of the eczematous process itself. Another feature sometimes incorrectly
ascribed to ichthyosis is the presence of increased prominence of the skin markings on the palms (Fig. 8.6) the so-called hyperlinear palms. In severely affected
patients, there is a background pinkness of the skin and ssuring at some sites
because of the inelasticity of the abnormal stratum corneum.
Virtually any body site can be affected. The face is often involved (Fig. 8.7) as
are the backs of the knees (Fig. 8.8), the antecubital fossae and the wrists.
108
Atopic dermatitis
Figure 8.9 Prominent crease beneath the eyes in a

child with atopic dermatitis Denny Morgan fold.
Figure 8.10 White dermographism.
The cheeks are often pale and this feature, taken together with crease lines just
below the eyes (known as Denny Morgan folds) due to continual rubbing, makes
the facial appearance quite characteristic (Fig. 8.9). Running a blunt instrument
(such as a key) over affected skin produces a white line in about 70 per cent of
patients (Fig. 8.10) known as white dermatographism. This is the reverse of the
normal triple response and disappears when the condition improves. This unexplained paradoxical blanching is similar to that seen after intracutaneous injection of methacholine or carbamyl choline in atopic dermatitis patients.
CLINICAL VARIANTS
In patients with black skin, there are often numerous follicular papules in
affected areas (Fig. 8.11). In lichenied areas in black-skinned patients, there
may be irregular pigmentation, with hyperpigmentation at some sites and loss
of pigment at others.
Some individuals lose their childhood eczema only to develop chronic palmar
eczema in later years. This is believed also to be a manifestation of atopic disease.
ASSOCIATED DISORDERS
Patients with atopic dermatitis quite often also suffer from asthma. Some 30 per
cent will also have had asthma before their skin disorder has healed. There is no
particular synchronization, and worsening or remission of one has no particular
implication for the other. Hay fever is also more common in atopic dermatitis
patients, but the activity and severity have no link to the skin disorder.
Atopic dermatitis, asthma and hay fever seem to share pathogenetic mechanisms
in which aberrant immune processes play an important part. These three atopic
109
Eczema (dermatitis)
Figure 8.11 Widespread

atopic dermatitis in a
young Asian subject.
disorders cluster in families and the tendency to one or the other or all is inherited
in an as yet uncharacterized way. Chronic urticaria (see page 71) and alopecia areata
(see page 271) occur more often in atopic dermatitis patients. The skin of patients
with atopic dermatitis is more vulnerable to both chemical and mechanical trauma
and has an unfortunate tendency to develop irritant dermatitis.
COMPLICATIONS
Patients with atopic dermatitis are frequently troubled by skin infections. Pustules
and impetiginized areas represent pyococcal infection and are the most common
expression of this propensity. They are easily treated, but tend to recur. Cellulitis
may also develop, giving rise to fever and systemic upset. Viral warts and mollusca
contagiosa are also more frequent and more extensive than in non-eczematous
subjects.
110
Atopic dermatitis
Herpes simplex sometimes causes a severe and extensive rash in atopic dermatitis patients, who may develop fever and severe systemic upset, but recover after
1014 days.
EPIDEMIOLOGY AND NATURAL HISTORY

Atopic dermatitis occurs in families, but the mode of inheritance has been difcult
to work out. It certainly does not appear to be the result of a single gene defect.
Approximately 30 per cent of patients with atopic dermatitis have one affected
parent and there is 90 per cent concordance in monozygotic twins.
The disorder is very common and is becoming more common. In some surveys,
approximately 15 per cent of infants have been found to suffer from atopic dermatitis. The overall prevalence in the community depends, amongst other things, on
the particular age structure, but in the UK it is approximately 2 per cent. Because
the disorder is resistant to treatment, often disabling and long lasting, it is very
common in dermatology clinics, affecting 1015 per cent of the clinic population.
The disorder mostly presents at 35 months of age (approximately 60 per cent), with
1520 per cent developing it before then and some 2030 per cent subsequently. Few
develop the disease in late childhood or early adult life. It affects both sexes equally
and all racial and social groups. Fortunately, it tends to improve and at every decade
there are fewer patients with the disease. It is said that some 75 per cent of those
troubled in early childhood are free of atopic dermatitis by the age of 15 years.
LABORATORY FINDINGS AND AETIOPATHOGENESIS
Skin biopsy reveals spongiosis, marked epidermal thickening parakeratosis and

an inammatory cell inltrate, oedema and vasodilatation in the dermis.
There is an elevation of serum IgE antibodies, which is correlated with the severity of the disease. These are reaginic, precipitating antibodies to various environmental allergens, including foods and inhaled materials, which become xed
to mast cells. When an allergen contacts its antibody xed on mast cells, mediators, including histamine, are released, causing an urticarial response. This
occurs in the positive reactions seen in scratch and prick tests. Atopic patients
often have multiple positives to food, house dust mite allergen and pollens,
but this seems to have little relevance to the cause, prevention or treatment of
their eczema.
The susceptibility to skin infection, the association with other disorders that
have an immunopathogenetic component and the elevated IgE level all suggest
an abnormality of the immune system. Part of the problem may be an imbalance
in the relative proportions of two subpopulations of T-helper lymphocytes
TH1 and TH2. The TH1 subset typically secretes gamma interferon and is
important in turning off the secretion of immunoglobulins by B-lymphocytes.
TH2 cells predominantly secrete interleukin-4 (IL4) and are thought to be
dominant in atopic dermatitis.
111
Eczema (dermatitis)
The importance of an enzyme (desaturase) deciency in the blood in atopic

dermatitis is uncertain. It results in a comparative deciency of unsaturated
fatty acids particularly dihomogammalinolenic acid.
MANAGEMENT
Several points need to be kept rmly in mind.
The disease is persistent and subject to recurrent ares, making it important to

develop a good relationship with patients and their immediate relatives.
The disorder causes much discomfort and disability because of the intense and
persistent itching. The sleep disturbance that results makes the whole family
unhappy.
The affected skin needs protection from further injury. The use of bland, greasy
emollients gives some symptomatic relief and provides this protection.
Infection often seems to play some role in the precipitation or aggravation of
the disease and antimicrobial treatments, both local and systemic, may rapidly
terminate an exacerbation.
Topical corticosteroids
Topical corticosteroids are the most useful topical agents for the treatment of atopic
dermatitis (see page 307). However, these drugs are only suppressive and need to be
given over long periods. Toxic side effects, such as skin atrophy, pituitaryadrenal axis
suppression and masked infection, are ever-present possibilities. Sudden withdrawal
of treatment can lead to a sudden and severe rebound aggravation of the eczema
and it is prudent to use the least potent corticosteroid preparation that is effective.
Topical corticosteroids may become less effective with continued use, but changing
to another preparation of similar potency will regain control. This phenomenon of
acquired tolerance is known as tachyphylaxis and is as yet unexplained.
There are many corticosteroids and less potent agents, such as hydrocortisone,
clobetasone 17-butyrate, urandrenolone and desoxymethasone, that are particularly suitable for infants with active eczema.
Creams, lotions and gels are less helpful vehicles for the corticosteroids and are
less useful than greasy ointments. Application once or twice daily is quite adequate.
Recently, a topical immunosuppressive agent tacrolimus (Protopic) has
become available. This agent is quite effective and does not have the skin-thinning
or pituitaryadrenal axis suppressive activity of corticosteroids.
Emollients
Emollients have hydrating effects on the skin in eczema because of their occlusive
properties. They reduce scaling and improve skin texture and appearance. They
improve the extensibility of skin and reduce ssuring as well as decreasing the
pruritus and inammation via unknown mechanisms.
All emollients seem to have much the same degree of effect providing they
are sufciently greasy and occlude the skin surface. The most important issues are
112
Atopic dermatitis
how frequently they are applied and whether the patient actually uses them! They
should be applied at least three times daily for the best effect and more frequently
if possible their effects only last 2 hours or so. A bath oil or an emollient skin
cleanser (e.g. emulsifying ointment BP) may also help.
Tar preparations
Coal tars are used for eczema and psoriasis. The generic preparations (e.g. tar ointment or tar and salicylic acid ointment BP) are not popular because of the smell and
messiness associated with their use, but modern proprietary preparations are more
acceptable (e.g. Clinitar cream). Their anti-inammatory action is little understood and they are best employed for chronic lichenied areas of eczema. They can
irritate the skin and have caused concern because of a potential for carcinogenicity.
Systemic agents
Some patients with severe disease do not respond to topical measures. For this
group there are several options. These include photochemotherapy with one or
another of ultraviolet radiation (see page 141), systemic steroids and cyclosporin.
Some patients improve after sun exposure, and phototherapy of some type
may be of assistance for them. This may help 5075 per cent of severely affected
patients, but has to be balanced against the long-term hazards of skin cancer (see
page 207 et seq.). Systemic steroids suppress the eczema, but the cost in severe longterm toxicity, including osteoporosis, skin fragility, susceptibility to infection and
pituitaryadrenal axis suppression, probably outweighs the short-term benets.
Cyclosporin is a fungal metabolite peptide with immunosuppressive effects
that is found to be helpful for some patients with severe psoriasis (see page 140).
It has been found to have a dramatic effect in patients with severe, generalized
atopic dermatitis at a dose of 35 mg/kg body weight per day. As with most effective drugs, there are toxic side effects, which, in the case of cyclosporin, include
nephrotoxicity and hypertension. None of these systemic drugs or photochemotherapy with UVA (PUVA) should be given without consultation with a specialist
with experience in the benets and side effects of the various treatments.
Unfortunately, cyclosporin does not work when employed topically.
Antimicrobial agents
Patients with atopic dermatitis are particularly prone to skin infection. Infection
with staphylococci and possibly other bacteria cause pustules, impetiginized lesions
and cellulitis and may also be responsible for are-ups of the dermatitis. This is
the reason why appropriate antibacterial measures by themselves seem to be
benecial. Bacterial swabs should be taken before starting treatment with either
topical or systemic antibacterial agents. Antimicrobial bath additives such as a povidone iodine or a hexachlorophane preparation may assist. The infected area can be
soaked or bathed in 1 in 8000 potassium permanganate solution or aluminium
subacetate solution. Topical neomycin or mupirocin may be used, but other antibiotics should be avoided because of the problem of resistance. If there is evidence
113
Eczema (dermatitis)
of signicant infection in several sites that may be aggravating the atopic state,
systemic antibiotics should be given, taking into account local and current policy
with regard to penicillin resistance.
DEFINITION
This is a common eczematous disorder that characteristically occurs in hairy
areas, on the exures and on the central parts of the trunk, and is now believed
to be at least in part due to overgrowth of the normal skin ora in the regions
affected.
CLINICAL FEATURES
Signs and symptoms
Reddened, itchy patches appear at the affected sites, which may become either scaly
or exudative and crusted. Scaling is a common feature when the condition
develops insidiously. Often, mild scaling occurs without erythema, as it does, for
example, on the scalp as dandruff . When severe, the eyebrows may also be
affected. Other facial areas may become involved such as the nasolabial folds, the
paranasal sites, the external ears and the retroauricular folds (Figs 8.12 and 8.13).
Figure 8.12 Diagram to show frequently

affected sites in seborrhoeic dermatitis.
Figure 8.13 Scaling area in the ear due
to seborrhoeic dermatitis.
114
(a)
(b)
Figure 8.14 (a) Exudative lesions of seborrhoeic dermatitis in the groin area. (b) Seborrhoeic dermatitis of intertriginous
areas in the groin of an obese woman.
Scaling and erythema of the eyelid margins (marginal blepharitis) may also occur.
Another type of lesions seen in seborrhoeic dermatitis is a form of folliculitis. This
seborrhoeic folliculitis is marked by numerous small papules and papulopustules
originating in the hair follicles. The usually commensal yeast-like micro-organism
Pityrosporum ovale seems to have taken on an aggressive role, causing the inammatory lesions seen.
OTHER SITES INVOLVED

The condition may also erupt suddenly and cause exudative lesions in the exures
(Fig. 8.14). This is especially likely to occur in the summer months in overweight
individuals. In the elderly, seborrhoeic dermatitis sometimes spreads rapidly,
becoming generalized. This erythrodermic picture is quite disabling, but fortunately quite uncommon.
The disorder causes considerable itchiness, as do all the eczematous disorders.
It also gives rise to soreness and much discomfort when it is exudative and affects
the major exures.
Round or annular scaling patches over the central chest (Fig. 8.15) and upper
back are particularly common in middle-aged and elderly men, as are erythematous areas in the groins, especially in the overweight. When acute and severe, the
condition becomes exudative and other exural sites such as the axillae and the
umbilicus also become involved (sometimes known as infectious eczematoid
dermatitis).
DIFFERENTIAL DIAGNOSIS
In the groin area, it is important to distinguish exural psoriasis (see page 129)
and ringworm infection (tinea cruris; Table 8.2). Ringworm rashes are usually
Figure 8.15 Annular lesion

on the chest in seborrhoeic
dermatitis.
115
Eczema (dermatitis)
Table 8.2 Differential diagnosis of rashes in the groin

Clinical features
Tests
Ringworm
Often not symmetrical, very itchy,

rapidly spreading
Microscopy and
culture of scales
Seborrhoeic
dermatitis/
intertrigo
Tends to be symmetrical and to involve

apices of groins, other areas
may be affected
None available
Clothing
dermatitis
May resemble seborrhoeic dermatitis,

likely to affect other areas
Patch testing
asymmetrical and do not reach up right into the groin apices. There is usually a
raised advancing edge to ringworm and a tendency to clear centrally. Mycological
testing is so simple and useful and the results of misdiagnosis so embarrassing
that all should become procient at skin scraping and recognition of fungal
mycelium (see page 38).
NATURAL HISTORY AND EPIDEMIOLOGY

The condition is common at all ages and in both sexes. Severe and widespread
seborrhoeic dermatitis is a particular problem for elderly men, but the milder
forms are no more common in the elderly than in younger age groups. Cradle
cap occurring in the newborn is probably not seborrhoeic dermatitis, but a
minor and transient abnormality of scalp desquamation. There is no racial
predilection for the disorder and it appears to affect all social groups and occupations. The disorder has become notorious as a sign of acquired immune deciency
syndrome (AIDS) and presumably this is a result of the underlying immunosuppression (see page 100). Left untreated, the condition waxes and wanes over
many years.
TREATMENT
The major aims in the treatment of seborrhoeic dermatitis are the removal of the
precipitating microbial cause and the suppression of the eczematous response.
For this purpose, topical preparations containing both 1 per cent hydrocortisone
and an imidazole such as miconazole or clotrimazole may be all that is required
for patients with limited disease. A preparation containing lithium succinate has
also been useful. Sulphur and salicylic acid preparations are antimicrobial and
keratolytic and, although inelegant, appear quite effective when all else fails!
Exudative intertriginous areas in the major body folds rapidly respond to bed
rest to avoid further friction between opposing skin surfaces and bland lotions
or weak, non-irritating antibacterial solutions for bathing and wet dressings.
116
Broad-spectrum systemic antibiotics should also be employed: ampicillin or a

tetracycline is suitable.

DEFINITION
Discoid eczema is a quite common eczematous disorder of unknown cause, distinguished by the appearance of reddened, scaling, rounded areas on the arms and legs.
CLINICAL FEATURES
Signs and symptoms
Slightly raised, pink-red, scaly discs, varying in diameter from 1 cm to 4 cm, appear
on the arms and legs and, less frequently, on the trunk (Fig. 8.16). The disorder is
usually quite itchy and the skin on the arms and legs is often dry as well.

Discoid eczema is one of the less common eczematous conditions, but is by no
means rare. It is most common in the middle aged and elderly. The condition usually lasts for a few months only.
Figure 8.16 Discoid eczema.

117
Eczema (dermatitis)
Table 8.3 Differential diagnosis of round, red, scaling patches

Disease
Features
Psoriasis
Well-dened, thickened, scaly plaques, usually multiple
Discoid eczema
Only a moderately well-dened edge; slightly scaly, pink

patches, limited in number
Ringworm
May be annular with central clearing; microscopy and culture

of scales will reveal fungal mycelium
Bowens disease
Often slightly irregular in shape; edge is well dened; biopsy

is decisive
The condition has to be distinguished from psoriasis, in which the margins are
more distinct; from ringworm, which usually spreads peripherally and has a raised
margin; and from Bowens disease, which is mostly restricted to the light-exposed
areas and is usually one or two solitary red, scaling patches (Table 8.3).
TREATMENT
Weak and moderately strong corticosteroid preparations (e.g. 1 per cent hydrocortisone, clobetasone or desoximethasone are all suitable) applied once or twice
daily usually suppress the disorder. Emollients and emollient cleansers are also
helpful as adjuncts.

DEFINITION
Eczema craquele is an uncommon eczematous disorder that occurs on the extensor
aspects of the limbs of elderly subjects and is characterized by a crazy paving
appearance.
CLINICAL FEATURES
Signs and symptoms
The most common affected sites are the shins, the fronts and sides of the thighs,
extensor aspects of the upper arms and forearms, and the back. Involved skin
is pink, roughened and supercially ssured, giving a crazed appearance (Fig.
8.17). The areas affected are more sore than itchy. The condition has a very
118
Figure 8.17 Eczema craquele note

the crazed appearance.
characteristic appearance and it is uncommon for it to be mistaken for any other

disorder.

The disorder is restricted to the elderly and is mainly seen in the newly hospitalized
or institutionalized individual where there is low ambient relative humidity and
after unaccustomed vigorous bathing.
It seems to be an unusual response of already vulnerable skin to minor mechanical and chemical trauma.
TREATMENT
The condition responds to emollients and, if necessary, 1 per cent hydrocortisone
ointment when the atmosphere is humidied and vigorous washing stops.
Lichen simplex chronicus (circumscribed

neurodermatitis)
DEFINITION
This is an intensely pruritic rash, sharply localized to one or a few sites, which is
characterized by thickening and exaggeration of the skin surface markings.
119
Eczema (dermatitis)
CLINICAL FEATURES
Signs and symptoms
The medial aspect of the ankle, the back of the scalp, the extensor aspects of the
forearms, the wrists and the genitalia are predisposed to this disorder. The condition
is extremely itchy and patients complain bitterly about the intense local irritation.
The lesions are characteristically raised, irregular, red plaques with well-dened
margins, which have exaggerated skin markings (lichenication) over the scaling
surface (Fig. 8.18). If the itching is persistent and intense and the resultant scratching vigorous, the affected sites may become very thickened, raised and excoriated.
The resultant lesion is known as a prurigo nodule (Fig. 8.19). When many such nodules occur over the surface, the condition is known as prurigo nodularis.

Figure 8.18 Lichen simplex
chronicus note the
exaggerated skin surface
markings.
The disorder is quite common in middle-aged subjects of either sex and all races.
It may be more common in the Indian subcontinent. It is a very stubborn and persistent disorder, which may stay unchanged for many years. Prurigo nodularis is
similarly stubborn and persistent.
Hypertrophic lichen planus (see page 145) may be difcult to distinguish, although
this disorder tends to be more mauve and be less regularly lichenied than lichen
simplex chronicus. Biopsy may be needed to distinguish these disorders with certainty. Lichen simplex chronicus may also resemble a patch of psoriasis.
PATHOLOGY AND PATHOGENESIS

Histologically, there may be striking epidermal hypertrophy, which, in extreme
cases, may resemble epitheliomatous change (pseudoepitheliomatous hyperplasia).
Figure 8.19 Prurigo

papules on the ankle.
120
Contact dermatitis
The persistent scratching causes an increased rate of epidermal cell production and
accounts for the hypertrophy. The cause of the pruritus is unknown.
TREATMENT
The condition tends to persist regardless of the treatment prescribed. Highpotency topical corticosteroids, intralesional corticosteroids or preparations of
coal tar are sometimes helpful.
Case 7
The persistent itching of the thickened, scaling patches around the ankles and at
the back of the neck was extremely distressing for 68-year-old Michael. A biopsy
showed only thickening of the epidermis and some inammation, which was
diagnosed as lichen simplex chronicus. Michael had had the condition for at least
6 years and nothing seemed to help. One Tuesday morning he woke up with much
less itching and by the end of the week it was clear that the condition had gone
into remission for no known reason!
Contact dermatitis
Contact dermatitis may be caused by a direct toxic action of a substance on the
skin the so-called primary irritant dermatitis or by a substance inducing a
delayed hypersensitivity reaction allergic contact dermatitis. Both are common
and cause considerable loss of work and disability.
PRIMARY IRRITANT DERMATITIS

Denition
Primary irritant dermatitis is an eczematous rash that results from direct contact
with toxic irritating materials.
Clinical features
Scaly, red and ssured areas appear on the irritated skin (Figs 8.20 and 8.21). The
hands are most frequently affected. The palmar skin and the palmar surfaces of
the ngers are often affected, but the areas between the ngers and elsewhere on
the hands may also be involved. The condition may become exudative and very
inamed if the substances contacted are very toxic. This form of contact dermatitis causes considerable soreness and irritation. The ssures make movement very
difcult and effectively disable the victims.
Differential diagnosis
The condition must be distinguished from allergic contact dermatitis by a carefully

taken history and patch testing (see below). Psoriasis of the palms may resemble
Figure 8.20 Primary irritant

contact dermatitis affecting
the back of the nger.
121
Eczema (dermatitis)
Figure 8.21 Primary

irritant contact dermatitis
affecting the back of the
hand.
contact dermatitis, but is usually accompanied by signs of psoriasis elsewhere.

Ringworm usually affects one palm only and is marked by diffuse erythema and
silvery scaling. If there is any doubt, scales should be examined for fungal mycelium
under the microscope.
Natural history and epidemiology
An irritant substance will injure anyones skin if there is sufcient contact. However,
some individuals are more prone to develop primary irritant contact dermatitis
especially atopic subjects and those with fair skins who sunburn easily.
The disorder is seen particularly often in manual workers (occupational dermatitis) and housewives (housewives eczema). Builders, mechanics, hairdressers,
cooks and laundry workers are some of the groups that are frequently affected.
The condition causes considerable economic loss from loss of work. Contact with
alkalis, organic solvents, detergent substances, cement and particulate waste is
often responsible.
Prevention and management
The identication of potential hazards, use of non-toxic substances, prevention of

skin contact, use of protective gloves, use of emollients and worker education are
all important in prevention. When present, the cause must be identied and further contact prevented. When the condition is severe, rest from manual work is
required. Emollients are an important part of treatment to make affected skin
more supple and to minimize ssuring. Weak and moderately potent corticosteroids should accelerate healing.
ALLERGIC CONTACT DERMATITIS

Denition
Allergic contact dermatitis is an eczematous rash that develops after contact with
an agent to which delayed (cellular) hypersensitivity has developed.
122
Contact dermatitis
Clinical features
The rash develops at the sites of skin contact with the allergen, but occasionally
spreads outside these limits for unknown reasons. The vigour and speed of the reaction vary enormously depending on the particular individual. When very acute, the
reaction develops within a few hours of contacting the responsible substance such
a speedy response is seen, for example, in the condition of poison ivy, which is
common in the USA. Itching is noticed at rst and then the area involved becomes
red, swollen and vesicular. Later, the area becomes scaled and ssured.
An enormous number of substances are capable of causing allergic contact
dermatitis. Nickel dermatitis is one of the commonest examples some 5 per cent
of women in the UK are said to be nickel sensitive. Affected individuals cannot
wear stainless-steel jewellery because of the nickel in the steel (Fig. 8.22) and
develop a rash beneath steel studs, clips and buckles. Patients who are nickel sensitive may also react to dichromate and other chromate salts.
Other examples include allergy to chemicals in rubber, for example mercaptobenzthiazole (MBT) and thiouram, and to formalin. These allergies may cause
dermatitis when wearing particular clothes, as, indeed, may sensitivities to dyes.
Allergies to lanolin (in sheep-wool fat and in many ointments and creams) and to
perfumes can cause dermatitis after the wearing of cosmetics. Lanolin, ethylene
diamine, vioform, neomycin and local anaesthetics may cause a dermatitis after
using a cream or an ointment. Dyes (such as the black hair dye paraphenylene
diamine) can also be the cause of allergic contact dermatitis (Fig. 8.23). Some
materials are notorious for causing sensitivity and are not often used topically
because of this, for example penicillin and sulphonamides.
Figure 8.22 Allergic contact

dermatitis to nickel in the
metal studs in a pair of
jeans.
Figure 8.23 Allergic contact dermatitis

due to paraphenylene diamine hair dye.
123
Eczema (dermatitis)
Natural history and epidemiology
Allergic contact dermatitis is quite common, but not as common as primary irritant dermatitis. It is rare in children and uncommon in the elderly. It is seen in all
racial groups, although less so in black-skinned individuals.
Diagnosis of allergic contact hypersensitivity
Accurate history taking and careful examination identifying all involved areas are
very important. The denitive technique for diagnosing allergic contact hypersensitivity is patch testing. In this test, possible allergens are placed in occlusive
contact with the skin for 48-hour periods and the area is inspected 48 hours after
removal of the patch. A positive test is revealed by the development of an eczematous
patch with erythema, swelling and vesicles at the site of application. In practice,
low concentrations of allergen are applied to avoid false-positive primary irritant
reactions.
In most cases, a battery of the commonest allergens in appropriate concentrations is applied. Such a battery is shown in Table 8.4.
Table 8.4 Common antigens used in patch testing and
concentrations in which they are used
Antigen
Nickel sulphate
Balsam of Peru
Colophony
Chlorocresol
PPD base
MBT
Formalin
Potassium dichromate
Wool alcohols
Epoxy resin (Araldite)
Chloroxylenol
Neomycin
Cobalt chloride
Dowicil 200
Parabens
Thiuram-mix
Mercapto-mix
Perfume-mix
Kanthon CG
Primin
Ethylene diamine
Benzocaine
PPD paraphenylene diamine; MBT mercaptobenzthiazole.
124
%
5
25
1
1
1
2
1
0.5
30
1
1
20
1
1
15
1
2
8
0.67
0.01
1
5
Antigen
pidermis
Dermis
T-lymphocyte
Peripheral
lymph
node
Figure 8.24 Diagram

to show the processes
in allergic contact
dermatitis. Antigen is
processed by
Langerhans cells in
the epidermis and
then presented to
T-lymphocytes.
antigen;
antigen processed
by Langerhans cell;
LC Langerhans cell.
The sensitizing chemical (antigen) crosses the stratum corneum barrier and is
picked up by the Langerhans cells in the epidermis (Fig. 8.24). The antigen is then
processed by the Langerhans cell and passed on to T-lymphocytes in the peripheral lymph nodes. Here, some of the T-lymphocytes develop a specic memory
for the particular antigen and the population of these expands. This process of
sensitization takes some 1014 days in humans. After this period, when the particular antigen contacts the skin, the primed T-lymphocytes with the memory for
this chemical species rush to the contacted site and liberate cytokines and mediators that injure the epidermis and cause the eczematous reaction.
Treatment
It is vital to identify the sensitizing material and prevent further contact. The
eczema will subside rapidly in most cases after removal from the antigen. The use
of weak or moderately potent topical corticosteroids and emollients will speed
the resolution of the eczematous patches.
Venous eczema (gravitational eczema;

stasis dermatitis)
DEFINITION
Venous eczema occurs on the lower legs and is the result of chronic venous
hypertension.
CLINICAL FEATURES
Itchy, pink, scaling areas develop on a background of the changes of chronic
venous hypertension (Fig. 8.25). The affected areas are often around venous ulcers,
but the margins of the eczematous process are poorly dened. Occasionally, the
process spreads to the contralateral leg and even to the thighs and arms.
125
Eczema (dermatitis)
Figure 8.25 Gravitational eczema.
In most cases, venous eczema is actually an allergic contact hypersensitivity to

one of the substances used to treat the venous ulcer. Such substances include lanolin, neomycin, vioform, ethylene diamine and rubber additives. It has been suggested that some patients develop a sensitivity to the breakdown products of their
own tissues (autosensitization).
TREATMENT
Contact hypersensitivity must be identied and the patient advised to stop using
the agent responsible. The simplest of topical applications should be used white
soft parafn is suitable as an emollient and 1 per cent hydrocortisone ointment is
suitable as an anti-inammatory agent.
Summary
Eczema (synonymous with dermatitis) is
characterized by epidermal oedema (spongiosis)
and may be caused by external factors or result
from poorly understood endogenous or
constitutional factors. The former types of eczema
include allergic contact dermatitis and primary
irritant contact dermatitis, whereas amongst the
latter are atopic dermatitis, seborrhoeic dermatitis,
discoid eczema and lichen simplex chronicus.
Atopic dermatitis is a very common, chronic,

remittent, extremely itchy dermatosis starting in
infancy. There is a marked tendency to occur in
families, probably via the inheritance of
susceptibility genes. The disease is strongly
associated with asthma and hay fever. There is
depression of cell-mediated immunity, enhancement
of immediate hypersensitivity and elevated serum
IgE. An imbalance between H1 and H2 populations
126
Summary
of T-lymphocytes with dominance of TH2 cells has

been proposed as the underlying problem.
Clinical features of atopic dermatitis include a
predilection for exural distribution of the eczema,
excoriations and lichenication, generalized
xeroderma, white dermographism, hyperlinear
palms and Denny Morgan folds beneath the eyes.
The skin often becomes infected with
Staphylococcus aureus, which may play a role in
relapses. There is a susceptibility to virus
infections, including multiple viral warts, mollusca
contagiosa and extensive herpes simplex.
Topical corticosteroids are the most effective
topical agents, but cause skin thinning and
pituitaryadrenal axis suppression as well as
rebound when their use ends. Emollients also have
major benets and most patients can be managed
with a combination of emollients and
corticosteroids. Very severely affected patients
may benet from some kind of phototherapy or oral
immunosuppressive drugs such as cyclosporin or
azathioprine, where the risk of severe side effects
is outweighed by the benets. Antimicrobial agents
may also be helpful.
Seborrhoeic dermatitis occurs on hairy sites and
exures or on the central trunk. Common signs are
severe dandruff and scaling, pink areas in the facial
exures. It affects major exures, particularly in the
elderly. Milder forms are very common. It appears
to be due to overgrowth of the normal follicular
ora and is often seen in the immunosuppressed
(e.g. AIDS). Treatment with weak corticosteroids
combined with antimicrobial agents such as the

imidazoles is often helpful.
Discoid eczema mainly occurs in the middle
aged and elderly and is characterized by round,
coin-sized, red scaling patches. It has to be
distinguished from psoriasis and Bowens disease.
Treatment is with emollients and corticosteroids.
Eczema craquele (asteototic eczema) occurs
particularly on the legs of elderly subjects with very
dry skin and is marked by a red rash with a crazy
paving pattern. It responds to frequent emollients.
Lichen simplex chronicus is an intensely pruritic
disorder, occurring in particular locations such as
the back of the neck and the medial aspects of
the ankles. Affected sites are well-dened, raised,
red, excoriated and lichenied plaques. The
condition is stubbornly persistent, but potent
topical corticosteroids may assist. Histologically,
there is marked epidermal thickening.
Primary irritant contact dermatitis is due to
toxic damage to the skin from alkalis and
surfactants and is mostly seen on the hands of
housewives and those who work with their
hands. Allergic contact dermatitis is due to the
development of delayed hypersensitivity to a
particular chemical substance such as nickel,
neomycin or a rubber additive in a few exposed
individuals.
Venous eczema occurs on the lower legs of elderly
individuals with venous hypertension. In some, it
seems to be due to allergic contact dermatitis to
agents used to treat venous ulcers.
127
C H A P T E R
Psoriasis and
lichen planus
Psoriasis
128
142
Lichen planus
144
Summary
147
Psoriasis
Psoriasis is important because of its frequency, its recurrent nature and its tendency to disable a proportion of its victims.
DEFINITION
Psoriasis is a common, genetically determined, inammatory skin disorder of
unknown cause, which, in its most usual form, is characterized by welldemarcated, raised, red scaling patches that preferentially localize to the extensor
surfaces.
CLINICAL FEATURES
The lesions
Typical lesions are red, raised and scaly and have well-demarcated margins
(Fig. 9.1). Plaques vary enormously in size and shape. They often start out discoid,
but end up polycyclic (Fig. 9.2) as several lesions coalesce.
Sites affected
Psoriasis affects the extensor aspects of the trunk and limbs preferentially. The
knees, elbows and scalp are especially frequently affected (Fig. 9.3), although the
mucosae seem to be spared.
128
Psoriasis
Figure 9.1 Typical red, scaling plaques of psoriasis on

the knees.
Figure 9.3 Psoriatic patch on the

elbow a site of predilection.
Figure 9.2 Polycyclic plaque of psoriasis.
The nails are often affected and may show the so-called thimble pitting, separation of the nail plate from the nail bed (onycholysis), subungual debris, brownish-black discolourations and deformities of the nail plate (Fig. 9.4).
Flexural lesions, which occur in some patients, are most often seen in the major
body folds in the elderly, especially in those who are overweight. The groins and
genitalia, axillae, inframammary folds in women and the skin of abdominal folds
and the umbilicus in either sex are affected. The moistness of the exural areas
decreases the scaling and produces a moist and glazed appearance (Fig. 9.5).
Figure 9.4 A minor degree

of involvement of the nail
plate with pitting and
onycholysis.
129
Psoriasis and lichen planus
Figure 9.5 Flexural psoriasis affecting

the body folds in an obese patient.
Figure 9.6 Psoriasis of the scalp margin.
Figure 9.7 Psoriasis appearing at sites of

injury (from scratching) the isomorphic
response.
The face is not usually severely affected in psoriasis, although the scalp margin,
paranasal folds and retroauricular folds are quite often involved (Fig. 9.6).
Psoriasis sometimes appears at the site of a minor injury such as a scratch or
a graze (Fig. 9.7). This reaction, known as the isomorphic response or the Koebner
phenomenon, mostly occurs when the psoriasis is in active spreading phase. The
development of a skin disorder at the site of injury is characteristic of psoriasis,
but is also seen in lichen planus (see page 144) and discoid lupus erythematosus
(see page 79). Its cause is unknown.

Surveys in the UK, the USA and Scandinavia have all reported that psoriasis is
found in between 1 and 3 per cent of the population. It has been claimed that the
130
Psoriasis
disorder is less common in African and Asian groups, but detailed gures are not
available. It seems less of a problem in the Japanese and other Asian populations,
but may be becoming more frequent with the trend to Westernization.
The disease is more common in men than in women. There are two main peaks
of incidence, the rst of which is in the second half of the second decade of life.
Recently, it has been recognized that psoriasis may also occur for the rst time in
the seventh decade. In general, the younger the age of onset, the worse the outlook
as far as frequency, severity and persistence of the disease are concerned.
Psoriasis is a life-long disorder subject to unpredictable remissions and relapses.
Single episodes are uncommon and in the most frequent variety an episode in the
teenage years is followed by a series of attacks, each lasting weeks or months, in
the succeeding years.
GENETICS
Psoriasis is often familial, but does not appear to be inherited in any regular dominant, sex-linked or recessive way. With one parent affected, there is an approximately 30 per cent chance of a child being affected. With both parents suffering
from psoriasis, the chance that a child will develop the condition rises to 60 per
cent. In a recent survey in Sweden, it was found that 6.4 per cent of relatives of
families in which there was a patient with psoriasis were affected, compared to
1.94 per cent of controls. Non-identical twins have an approximately 20 per cent
chance of both being affected, and the concordance rate for identical twins seems
to be in the order of 70 per cent. Recent research indicated that, although no one
gene is responsible for the disease, the direct inheritance of susceptibility genes is
necessary for its development.
Psoriasis is associated with HLA groups HLA-B13, HLA-B17 and HLA-B37 as
well as with the class II antigen DR7. It is even more strongly associated with CW6
increasing the risk of the disease some 13 times in Caucasians.
Any red, scaling disorder can be mistaken for psoriasis, and vice versa (Table 9.1).
On the scalp, the most frequently seen disorder to be mistaken for psoriasis is seborrhoeic dermatitis (see page 114), although this usually affects the scalp diffusely
rather than in distinct plaques. Lichen simplex chronicus (see page 119) of the
scalp typically presents with a red, scaling patch on the occiput, which can look
very psoriasis-like. The intense itching and lichenied surface should serve to distinguish the two disorders.
Multiple patches of ringworm may appear very like psoriasis (Fig. 9.8), but the
lesions are often more ring-like than psoriasis and can be distinguished by microscopical examination of potassium hydroxide (KOH)-treated skin scrapings (see
page 38). Mycosis fungoides a T-cell lymphoma of skin often evolves through
a phase in which there are many red psoriasiform lesions on the trunk, but these
differ from psoriasis by being more irregular in shape and persistent.
Figure 9.8 Psoriasiform

plaque in the leg due to
ringworm.
131
Table 9.1 Differential diagnosis of red, scaling rashes

Discriminants
Psoriasis
Nail changes, family history, multiple patches

on extensor surfaces
Discoid eczema
Round, scaly patches on arms and legs
Lichen simplex chronicus
Itchy, lichenied, persistent patches
Bowens disease
Plaques tend to be smaller and more limited

in number; biopsy decides
Supercial basal cell carcinoma
Thin, slightly raised edge; biopsy decides
Mycosis fungoides
Multiple psoriasiform patches, but irregularly

thickened; biopsy helps
Ringworm
Often annular, spreads peripherally;

microscopy and culture of scale important
Figure 9.9 Red, scaling

patch on the palm due
to psoriasis. Such a
presentation can be very
difcult to distinguish
from eczema.
On the legs, raised, round, red, scaling psoriasiform patches often turn out
to be Bowens disease in the elderly, or discoid eczema. Lichen simplex chronicus
around the ankles may also be difcult to distinguish.
Psoriasis of the palms (Fig. 9.9) is difcult to distinguish from eczema affecting these sites. Even after biopsy, the clinician may remain uncertain.
Supercial basal cell carcinoma lesions are sometimes several centimetres in
diameter and quite psoriasiform in appearance, but have a ne, raised, hair-like
margin.
CLINICAL VARIANTS
Guttate psoriasis
This disorder is mainly seen in children aged 714 years. Often, it develops some 24
weeks after an episode of tonsillitis or pharyngitis, mostly due to beta-haemolytic
132
Psoriasis
Figure 9.10 Multiple small patches of

guttate psoriasis seen after a streptococcal
tonsillitis.
streptococci. It behaves like an exanthem, as the characteristically drop-sized

lesions develop suddenly (Fig. 9.10) and at the same time. The lesions do not usually last longer than 810 weeks.
Napkin psoriasis
Infantile napkin dermatitis (see page 229) sometimes takes on a very psoriasis-like
appearance and typical psoriatic lesions develop on the scalp and trunk. The true
relationship with psoriasis is unknown.
Erythrodermic psoriasis
Psoriasis sometimes progresses to generalized skin involvement. Typical plaquelike lesions disappear, the skin is universally red and scaly and the condition is
known as erythrodermic psoriasis. Patients who are seriously ill suffer from:
heat loss, and are in danger of hypothermia because of the increased blood
supply to the skin
water loss, leading to dehydration because of the disturbed barrier function of
the abnormal stratum corneum
a hyperdynamic circulation, because effectively there is a vascular shunt in the
skin; when the patients myocardium is already compromised because of other
factors, there is a danger of high output failure
loss of protein, electrolytes and metabolites via the shed scales and exudates;
patients may develop deciency states.
133
Figure 9.11 Typical pustular psoriasis

affecting the sole of the foot.
Figure 9.12 Pustular psoriasis of the sole of the foot

with several older, brown, scaling lesions that were
pustules.
Pustular psoriasis
Most dermatologists consider this to be a manifestation of psoriasis, although

there are some who believe it is a separate disorder. It seems probable that pustular psoriasis is indeed a type of psoriasis, with exaggeration of one particular component of the disease (see Pathology below). There are two main types.
Palmoplantar pustulosis
Patients with palmoplantar pustulosis develop yellowish white, sterile pustules on
the central parts of the palms and soles (Figs 9.11 and 9.12). Older lesions take on
a brownish appearance and are later shed in a scale at the surface. The affected
area can become generally inamed, scaly and ssured and, although relatively
small areas of skin are affected, the condition can be very disabling.
The disorder tends to be resistant to treatment (see below) and is subject to
relapses and remission over many years.
Generalized pustular psoriasis
This is also known eponymously as Von Zumbusch disease, and is one of the most
serious disorders dealt with by dermatologists. In its classical form, attacks occur
suddenly and are characterized by severe systemic upset, a swinging pyrexia,
arthralgia and a high polymorphonuclear leucocytosis accompanying the skin
disorder.
The skin rst becomes erythrodermic and then develops sheets of sterile pustules over the trunk and limbs (Fig. 9.13).
134
Psoriasis
Figure 9.13 A 10-year-old

boy with severe generalized
pustular psoriasis.
Sometimes, the pustules become conuent so that lakes of pus develop just
beneath the skin surface. In other areas, there is a curious type of supercial peeling without pustules forming.
These patients are very unwell and require hospitalization. They can usually be
brought into remission by modern treatments (see below), but are subject to
recurrent attacks. The disorder sometimes affects infants and small children.
Other forms of pustular psoriasis
Occasionally, pustules may develop after strong topical or systemic corticosteroids
have been used and then abruptly withdrawn. Other rare variants of pustular psoriasis include:
acrodermatitis continua, in which there is a recalcitrant pustular erosive disorder on the ngers and toes around the nails and occasionally elsewhere
pustular bacterid, in which sterile pustules suddenly appear on the palms, soles
and distal parts of the limbs after an infection.
Arthropathic psoriasis
There is a higher prevalence of a rheumatoid-like arthritis with symmetrical

involvement of the small joints of the hands and feet, wrists and ankles in patients
with psoriasis (56 per cent) compared to a matched control population (12 per
cent). This rheumatoid arthritis-like disorder differs in one important respect
from ordinary rheumatoid arthritis there is no circulating rheumatoid factor.
In addition, there is a distinctive and destructive form of joint disease that
seems specic to psoriasis. In this psoriatic arthropathy, the distal interphalangeal
joints, the posterior zygohypophysial, the temporomandibular and the sacroiliac
135
Figure 9.14 The results of psoriatic arthropathy

(arthritis mutilans).
Figure 9.15 Regular epidermal thickening in psoriasis

with parakeratosis. There are cells at the base of the
epidermis that are darkly labelled by the process of
autoradiography after incubation in radiolabelled
thymidine, indicating that they are in the DNA synthesis
phase of cell division.
joints are particularly affected. The disorder is more destructive than rheumatoid
disease. Bony erosion and destruction take place, leading to collapse of affected
digits (Fig. 9.14), justifying the term often used for this dreadful disease arthritis
mutilans.
Treatment may temporarily improve these joint complications of psoriasis, but
they tend to run a progressive course subject to remissions and relapses.
PATHOLOGY AND PATHOGENESIS

The histopathological appearance of psoriasis is distinctive but not specic. The
main features may be subdivided into (1) the epidermal thickening, (2) the inammatory component, and (3) the vascular component, but of course all are closely
interlinked.
The epidermal thickening
The epidermis shows marked exaggeration of the rete pattern and elongation
of the epidermal downgrowths with bulbous, club-like enlargement of their ends
(Fig. 9.15). The average thickness is increased from about three to four cells in the
normal skin to approximately 1215 cells in the psoriatic lesion. Many mitotic gures can be seen and the rate of epidermal cell production seems to be greatly
enhanced. The turnover time of psoriatic epidermis and stratum corneum is consequently very much shortened. Normally, it takes some 28 days for new cells to
ascend from the basal layer and travel through the epidermis and the stratum
corneum and reach the surface. In psoriasis, it takes some 4 days! Epidermal
nuclei are retained in the inefcient horny layer that results (parakeratosis).
136
Psoriasis
Figure 9.16 Photomicrograph showing

many inammatory cells in the thickened
epidermis in psoriasis.
The inammatory component
Interspersed between the parakeratotic horn cells are collections of desiccated

polymorphonuclear leucocytes known as Munro microabscesses. The epidermis
is oedematous and is itself inltrated by inammatory cells. The dermis immediately below the epidermis also contains many inammatory cells, mostly lymphocytes. In pustular psoriasis, the epidermal component is much less in evidence
and there are collections of inammatory cells within the epidermis (Fig. 9.16).
The vascular component
The papillary capillaries are greatly dilated and tortuous to a degree not seen in
other inammatory skin disorders. Ultrastructurally it can be seen that there are
larger gaps than usual between the endothelial cells. These abnormal capillaries
are the last of the features to go during resolution.
AETIOLOGY
The cause of psoriasis is unknown, despite the enormous research effort that
has been made in the past three decades. Various hypotheses have been popular
at different times. One very obvious abnormality in psoriasis is the hyperplastic
epidermis with increased mitotic activity, and one line of intense investigation
was directed at the control of epidermal cell production in this disease. Attention
has moved away from this possibility in recent years and focused more on the
137
inammation and possible immunopathogenesis. The disorder often responds

to immunosuppressive agents such as cyclosporin and methotrexate and currently
psoriasis is thought of as a lymphocyte-driven disease.
Various potentially heritable biochemical abnormalities have been suggested
and/or described that could explain both the increased epidermal proliferation and
the inammatory component. At different times, alterations in the skin content or
activity of cyclic nucleotides, polyamines, eicosanoids, cytokines and growth factors have been described, but in most cases these changes are secondary to the
underlying and fundamental less well-characterized events.
Infection has been considered as a cause and in recent years the involvement of
retroviruses has been suggested. It is worth noting that in acquired immune deciency syndrome (AIDS) patients, a very acute and aggressive form of psoriasis
may develop.
Case 8
Jessies mother and aunt had psoriasis and at the age of 19 Jessie thought that
she was getting it too, as she had scaling patches on her knees and elbows and in
her scalp. She also noticed some separation of the nail plates from the nail beds
and pitting of three of her ngernails. Her GP diagnosed psoriasis and started her
on a tar preparation, which she didnt like because it burnt and soiled her clothes.
However, she did quite well with a later treatment calcipotriol (Dovonex). The rash
disappeared after 6 weeks, but unfortunately recurred the following year.
TREATMENT
Patients with just a few plaques affecting the knees, elbows or elsewhere require
little treatment. In other patients, simple treatment with an emollient such as
white soft parafn, by itself or with 2 per cent salicylic acid, is sufcient when
used once or twice daily.
With more lesions and symptoms, more active topical treatment is needed.
Tar-containing preparations are less popular than previously, but may suit
some patients who can put up with the stinging, the unpleasant smell and the
staining. Tar has anti-inammatory and cytostatic activity and certainly has
mild anti-psoriatic effect. Proprietary tar preparations have some advantages
over the British National Formulary formulations. Tar shampoos for scalp
involvement are still popular.
Analogues of vitamin D3 are effective topical treatments; calcipotriol used once
or twice daily improves some 60 per cent patients after 6 weeks treatment. Used
alongside medium-potency corticosteroids, the efcacy is increased and the skin
imitation decreased. A preparation of calcipotriol formulated together with
betamethasone-17-valerate is now available as Dovobet, and does appear quite
effective. Tacalcitol is another vitamin D3 analogue, which, although effective
when employed topically, is not as potent as calcipotriol. Apart from skin irritation, there is the concern that sufcient of these D3 analogues will be absorbed to
cause hypercalcaemia. Fortunately, this has not proved to be a problem thus far.
138
Psoriasis
Anthralin (dithranol) is a potent reducing agent that has marked therapeutic

activity in psoriasis. It is generally used in ascending concentrations, starting
at 0.1 or 0.05 per cent. To make dithranol treatment suitable for out-patients,
the tendency has been to use either dithranol in white soft parafn or one of the
proprietary preparations such as Dithrocream, which is available in different
strengths. Dithranol often irritates and burns the skin and care must be taken to
match the concentration used to the individual patients tolerance. It also causes
a distinctive brown-purple staining of clothes, towels and skin (Fig. 9.17). Apart
from the irritation and staining, dithranol has no serious side effects.
There is only a very limited role for topical corticosteroids in the treatment
of psoriasis. They are useful for patients with exural lesions for which other
irritant preparations are not suitable. For the same reason, weak topical
corticosteroids are also suitable for lesions on the genitalia and the face. Potent
topical corticosteroids should not be used, because frequent use is likely to lead
to side effects (see page 307) and because eventual withdrawal may lead to
severe rebound and even the appearance of pustular lesions. Potent topical
steroids (such as uocinolone acetonide or betamethasone dipropionate) may
be suitable for use on the scalp and their use is sometimes justiable on the
palms and soles if other treatment is not helping.
Another quite new treatment is a topical retinoid analogue called tazarotene
(0.05 or 0.1 per cent). This is really very effective giving some 65 per cent
improvement in 6 weeks. When used alongside medium-potency topical corticosteroids, its efciency is increased and the irritation experienced by some
15 per cent of users is decreased.
Figure 9.17 Brownishpurple staining on the skin

due to dithranol.
Both the vitamin D3 analogues and tazarotene may improve psoriasis by

modulating gene activity and redirecting differentiation and by reducing the
epidermal proliferation. When more than 15 per cent of the body surface area
is involved, topical treatment becomes very difcult. The same is true of erythrodermic psoriasis and generalized pustular psoriasis. All these types require systemic treatments.
Methotrexate
The antimetabolite methotrexate is a competitive antagonist of tetrahydrofolate

reductase, blocking the formation of thymidine and thus DNA. It is thought that
this antiproliferative activity may be important in reducing epidermal and lymphocyte proliferation. Whichever way it works, it is a highly effective treatment for
patients with severe psoriasis. Unfortunately, it is also quite toxic, producing hepatotoxicity in most patients who stay on the drug for long periods. The drug also
suppresses haematopoiesis and may cause gastrointestinal upset.
It is given once weekly in doses of 525 mg orally or intramuscularly. To minimize the possibility of serious side effects, patients must be monitored frequently
(preferably monthly) by blood counts and blood biochemistry. It is recommended
that a liver biopsy is performed both before treatment begins and after a cumulated dose of 1.5 g methotrexate.
139
Methotrexate is also a teratogen, and fertile women should use contraceptive

measures. It is mainly suitable for those who would otherwise be disabled by the
disease, and for some elderly patients with severe psoriasis.
The retinoids
Retinoids are analogues of retinol (vitamin A) and have been found to exert
important actions on cell division and maturation. The orally administered
acitretin is of particular value in psoriasis. The drug benets patients with all
types of severe psoriasis after 34 weeks, but is of most help when used in combination with ultraviolet treatment. Its major drawback is that it is teratogenic and
can only be given to fertile women if they use contraception and are prepared to
continue using the contraceptive measures for 3 years after stopping treatment.
Other signicant toxicities include hyperlipidaemia and a possibility of hyperostosis and extraosseous calcication. In addition, it does have some hepatotoxicity
in a few patients (Table 9.2). These signicant toxicities are not common, but
minor mucosal side effects occur in all patients, including drying of the lips and
the buccal, nasal and conjunctival mucosae. Minor generalized pruritus and slight
hair loss also occur. Oral retinoids should only be prescribed by dermatologists,
i.e. those who are familiar with their effects.
Cyclosporin
Cyclosporin is an immunosuppressive agent used in organ transplantation. It

appears to work by inhibiting the synthesis of cytokines by T-lymphocytes. It is
Table 9.2 Toxic side effects of etretinate and acitretin

Toxic side effect
Major
Teratogenicity
Comment
Contraception necessary for fertile women;

should be continued for 3 years after stopping
Hyperlipidaemic effect
Causes a rise of serum lipids in about 30% of

patients; low-fat diet required
Hepatotoxicity
Possible but uncommon
Bone toxicity
Disseminated interstitial skeletal hyperostosis

and other changes in chronic use
Minor
Drying and cracking of lips
In most patients
Drying of eyes and nose
In about 25% of patients
Increased rate of hair loss
Pruritus, peeling palms

and soles
140
Psoriasis
also dramatically effective in psoriasis when given in doses of 35 mg/kg per day.
Its toxic side effects include severe renal damage and hypertension. Its place in the
treatment of disabling and severe psoriasis is assured, but great care and constant
monitoring are required.
Treatment with ultraviolet radiation
Ultraviolet radiation (UVR) has long been known to have therapeutic effects in a
number of skin disorders, including psoriasis. A form of UVR treatment known
as PUVA is mainly used. PUVA is an acronym for photochemotherapy with ultraviolet radiation of the A (long-wave) type. The UVA is supplied by special uorescent lamps that emit at wavelengths of 300400 nm, housed in cabinets or
special frames over beds.
A photosensitizing psoralen drug is given orally 2 hours before exposure. The
main psoralen used is 8-methoxy psoralen, but 5-methoxy psoralen and trimethoxy
psoralen are sometimes used. The dose of 8-methoxy psoralen is 0.6 mg/kg. Alternatively, the patient bathes in water containing a psoralen and is then exposed to
UVR a few minutes later.
Ordinary sun lamps emitting UVB (290320 nm) can also be used to treat
psoriasis. The dangers of burning may be greater and the dangers of skin cancer
are similar to PUVA.
Both PUVA and UVB can be combined with topical dithranol, calcipotriol and
tazarotene or oral acitricin. These combinations reduce the danger of side effects
from UVR and reduce the likelihood of toxicity from the accompanying agent.
The dose of UVA is calculated (in Joules) from the output of the lamps and the
time of exposure. The dose required for clearance is approximately 50100 J/cm2
and care is taken to keep the dose as low as possible and certainly below a total
cumulated dose of 1500 J/cm2 to reduce the possibility of long-term side effects.
There are several long-term side effects (Table 9.3).
Increased incidence of squamous cell carcinoma of the skin (see page 207) up
to 10 or 12 times that in a control group of psoriatics after 10 years. Carcinoma
of the external genitalia in men is a particular problem. There is an increased
incidence of basal cell carcinoma and melanoma as well.
Increased solar elastotic degenerative change, with the appearance of ageing
and alteration of skin elasticity.
Cataracts can develop and all patients who receive PUVA must wear effective UVA protective goggles or sunglasses during exposure and for 24 hours
afterwards.
In the short term, nausea is often experienced and, if too long an exposure is
given, burning can occur. Patients who are sensitive to the sun or who coincidently have a disorder that can be aggravated by UVA exposure, such as lupus
erythematosus or porphyria cutanea tarda, should not be treated by PUVA.
So-called narrow-band UVR is UVR at a wavelength of 311 nm. It has recently
been introduced as an effective and less hazardous form of UVR treatment
(although there is uncertainty on this issue).
141
Table 9.3 Side effects of PUVA treatment

Side effects
Major (long term)
Skin cancer
Comment
Considerable increase in incidence of squamous cell

carcinoma and, to a lesser extent, other types of skin
cancer
Cataract
UVA-screening spectacles must be used during and

24 hours after exposure
Photoageing
Damage to the dermis results in the appearance of

ageing and altered elastic properties
Minor (short term)

Nausea
Probably due to the psoralen if taken orally
Burning
In some sensitive people, or if the dose of UVR is

too great
Pruritus and xeroderma
Emollients are helpful
Other treatments
Numerous other treatments have been investigated in the past few years. These
range from propylthiouracil to fumaric acid derivatives and new immunosuppressive agents such as tacrolimus.

DEFINITION
Pityriasis rubra pilaris is an uncommon skin disorder of unknown cause, which
often has a supercial resemblance to psoriasis as it is characterized by redness
and scaling, but has a distinctive histological appearance and a distinctive component of follicular involvement.
CLINICAL FEATURES
The commonest type of pityriasis rubra pilaris occurs in the late middle-aged or
elderly and is often of sudden onset. Usually, the disease begins on the face and
scalp, with pinkness and scaling, and spreads within a few days or a week or two
to involve the rest of the body. There is a characteristic orange hue to the redness,
and on the thickened palms there is a characteristic yellowish discoloration
(Fig. 9.18). Scattered amongst the red, scaling eruptions are islands of spared
142
Figure 9.18 Palmar thickening due to hyperkeratosis in

pityriasis rubra pilaris.
Figure 9.19 An island of white spared skin in pityriasis

rubra pilaris.
Figure 9.20 Follicular

distribution of eruption in
pityriasis rubra pilaris.
white skin (Fig. 9.19), and on the hands, thighs and sometimes elsewhere there
is a typical follicular accentuation due to the presence of hyperkeratotic spines
(Fig. 9.20).
There is also an infantile type which, although similar in many ways to the
adult form, tends to be much more stubborn and resistant to treatment.
The histological appearance is distinctive in that, although there is considerable
epidermal thickening, the accentuation of the dermal papillae and the undulations of the dermoepidermal junction are much less marked than in psoriasis.
TREATMENT
Many patients respond well to oral retinoids by mouth (see page 140) given in
the same manner as for psoriasis. Treatment by methotrexate has also been
advocated.
143
Figure 9.21 Red-mauve papules of lichen planus.

Some of these have a faint white network pattern on
the surface (Wickhams striae).
Figure 9.22 Many papules of lichen planus affecting

the wrist.
Lichen planus
DEFINITION
Lichen planus is an inammatory disorder of skin of unknown origin but with a
prominent immunopathogenetic component. It is characterized by an eruption of
variable extent of typical mauve or pink, at-topped, itchy papules.
CLINICAL FEATURES
The typical lesion of lichen planus is a mauve or pink, at-topped, polygonal
papule, which often has a whitish lacework pattern on its surface (Wickhams
striae) (Fig. 9.21). The papules are often aggregated in some sites, for example the
front of the wrist (Fig. 9.22), but may also occur scattered sparsely over the skin
of the limbs and trunk. Usually, only a few lesions develop, but in some cases the
eruption may be dense and generalized.
The mucosae are often affected and lesions occur in the mouth in some 30
per cent of patients. A white lacework pattern on the buccal mucosa is the most
frequently observed type of lesion (Fig. 9.23), but the tongue and elsewhere in the
mouth may also be involved, with white lacework, whitish macule or punctuate
lesions. The male genitalia are also sometimes affected (Fig. 9.24). The nails
develop longitudinal ridges in 510 per cent of patients (Fig. 9.25). Less commonly, a destructive process develops in which the nail plate is lost and the nailforming tissue (the nail matrix) is damaged.
The scalp is sometimes affected and then localized patches of hair loss and
scalp scarring occur.
As lesions heal, they atten and often leave a pigmented patch, which persists
for some weeks.
144
Lichen planus
Figure 9.23 White lacework pattern on

the buccal mucosa due to lichen planus.
Figure 9.25 Longitudinal
ridging of the nails in lichen
planus.
Figure 9.24 Lichen planus papules
affecting the glans penis.
Figure 9.26 Thickened patch of hypertrophic lichen planus.
The commonest variant is hypertrophic lichen planus, in which thickened, mauvish papules or nodules of irregular shape with a warty or scaling surface develop
(Fig. 9.26). Solitary hypertrophic lesions may appear in the course of ordinary
lichen planus or develop as solitary lesions.
145
Annular lichen planus describes the situation in which lichen planus lesions
have fused to give a ring-type conguration. This odd variant sometimes occurs
on the male genitalia and lower abdomen, but rarely elsewhere.
Lichen nitidus is a rare variant of lichen planus in which numerous tiny, pink,
at-topped papules develop.
Bullous lichen planus is a very rare variant in which blistering occurs on some
lesions.
Lichen plano-pilaris predominantly involves the hair follicles. Affected sites lose
their terminal hair and develop horny spines, which project from the affected hair
follicles.
AETIOPATHOGENESIS
Lichen planus appears to be in the general category of autoimmune diseases and
patients affected by it have a higher frequency of other autoimmune disorders
than a comparable unaffected population. Myasthenia gravis and vitiligo seem
particularly associated.
The disease is not uncommon in Europe, possibly accounting for some 24
per cent of new patients in skin clinics, but is quite uncommon in the USA. It appears
to be a more frequent problem in parts of Asia. There does not seem to be a major
genetic component to the disease.
Most patients are free of lesions after a year. Hypertrophic lesions tend to last
for many years.
There are characteristic histopathological changes (Fig. 9.27).
(a)
A band of lymphocytes and histiocytes immediately subepidermally. Amongst

the inammatory cell inltrate are clumps of melanin pigment as a result of
damage to the epidermis.
(b)
Figure 9.27 (a) Pathology of lichen planus showing typical changes, with a band of lymphocytes and histiocytes in
the subepidermal region (lichenoid band) and epidermal thickening with hypergranulosis, but a sawtooth pattern
of erosion in the basal epidermal region. (b) Detail of the pathology of lichen planus showing the basal epidermal
region with erosion, cytoid bodies and a dense lymphocytic inltrate.
146
Summary
Damage to the basal epidermal cells causing a sawtooth prole, vacuolar

degenerative change and scattered eosinophilic cytoid bodies representing
dead epidermal cells.
Variable epidermal thickening with increase in thickness of the granular cell layer.
Immunouorescence studies show a dense, ragged band of brin at the dermoepidermal junction and clumps of IgM deposit.
The basic process is thought of as an immunological attack on the basal layer;
the presence of inammatory cells and the other epidermal alterations are
believed to be secondary events.
TREATMENT
The disease mostly remits spontaneously, so that most patients require very little
treatment. Weak topical corticosteroids may be helpful in relieving the pruritus.
When patients are severely affected with a generalized eruption, systemic corticosteroids are sometimes helpful, as is the oral retinoid acitretin.
Summary
Psoriasis
Psoriasis is a genetically determined, persistent
and/or recurring inammatory dermatosis, which
occurs in 12 per cent of the population. It usually
starts between the ages of 15 and 25, but in some
patients it develops in the 60s.
It is characterized by raised, red, rounded, scaling
patches of variable size that tend to occur on the
elbows, knees, scalp and other extensor
surfaces.
Nail involvement occurs in many patients and is
characterized by thimble pitting, subungual debris
and areas of discoloration.
Variants include guttate psoriasis with myriads of
tiny psoriatic patches, exural psoriasis, generalized
pustular psoriasis and a localized form of pustular
psoriasis occurring on the palms and soles, and
erythrodermic psoriasis.
Psoriasis needs to be distinguished from other red
scaling conditions, including eczematous disorders
such as seborrhoeic dermatitis, lichen simplex
chronicus and discoid eczema, ringworm infections
and neoplastic disorders such as Bowens
disease and supercial basal cell carcinoma.
A seronegative rheumatoid arthritis-like condition

occurs in 56 per cent of patients with psoriasis. In
addition, in a few psoriatics, a distinctive
arthropathy affects the terminal interphalangeal
joints (arthritis mutilans) as well as other small and
medium-sized joints.
Histologically, the epidermis is greatly thickened and
hyperplastic, with accentuation of the rete pattern.
There is increased mitotic activity and decreased
epidermal replacement time. The epidermis is
surmounted by an incompletely differentiated
stratum corneum in which the nuclei are retained.
Also within the stratum corneum are collections of
nuclei from polymorph leucocytes (Munro
microabscesses). Polymorphs also inltrate the
thickened epidermis and there is a variable degree
of lymphocytic inltrate beneath the epidermis. The
papillary capillaries are dilated and tortuous.
The cause of psoriasis is unknown, but it is
currently thought of as a lymphocyte-driven disorder
in genetically susceptible individuals.
Topical treatments include tar preparations
(16 per cent), anthralin (0.15 per cent)
vitamin D analogues (calcipotriol and tacalcitol)
147
and a novel stable acetylenic retinoid known as

tazarotene.
Some patients with extensive psoriasis benet
from treatment with one or another form of UVR.
Sensitization with psoralens and radiation with
long-wave UVR (known as PUVA) is an effective
method, but may cause skin cancers when used
over the long term.
Severely affected patients may require oral
treatments such as methotrexate, cyclosporin and
acitretin, all of which may cause serious adverse
side effects.
Lichen planus
Lichen planus is a self-limiting, not uncommon
inammatory disorder of skin and mucosae
of unknown origin, but with a prominent
immunopathogenetic component.
Mauve, at-topped, itchy, angulated papules

develop, on which a white lacework tracery
(known as Wickhams striae) may be seen.
The number of papules varies from just a few
to myriads.
A white network appears on the buccal mucosa
in about 30 per cent of patients and lesions may
also appear on the genitalia.
Micropapular and hypertrophic variants are seen.
The condition may also affect the scalp, causing
areas of alopecia as well as involving the nails.
Histologically, there is damage to the basal layer of
the epidermis, with the formation of cytoid bodies
as well as a prominent inltrate of lymphocytes and
histiocytes subepidermally. The disorder is thought
to be autoimmune in nature.
Treatment with topical corticosteroids may help to
relieve the itch, but the condition is self-limiting.
148
C H A P T E R
10
Acne, rosacea and

similar disorders
Acne
149
Rosacea
162
Perioral dermatitis
168
Summary
169
The disorders described in this chapter are common, inammatory, characterized

clinically by papules and occur on the face pre-eminently. These features do not
imply a common aetiopathogenesis.
Acne
Acne is one of the commonest skin disorders if not the commonest. It has been
estimated that 70 per cent of the population have some clinically evident acne at
some stage during adolescence!
DEFINITION
Acne (acne vulgaris) is a disorder in which hair follicles develop obstructing
horny plugs (comedones), as a result of which inammation later develops
around the obstructed follicles, causing tissue destruction and scar formation.
CLINICAL FEATURES
The lesions
The earliest feature of the disorder is an increased rate of sebum secretion, making the skin look greasy (seborrhoea). Blackheads or comedones usually accompany the greasiness. They often occur over the sides of the nose and the forehead,
but can occur anywhere (Fig. 10.1). Comedones are follicular plugs composed
149
Acne, rosacea and similar disorders
Figure 10.1 Multiple comedones and

seborrhoea in acne.
Figure 10.2 Multiple comedones in acne.

Note the blackened tips from melanin.
of follicular debris and compacted sebum. They have pigmented tips from the
melanin pigment deposited by the follicular epithelium at this level (Fig. 10.2).
Accompanying the visible comedones are numerous invisible comedones, many
of which do not have pigmented tips.
Inamed, reddened papules develop from blocked follicles. These are often
quite tender to the touch and may be set quite deep within the skin (Fig. 10.3).
Sometimes they develop pus at their tips (pustules), but these may also arise independently. In a few patients, some of the papules become quite large and persist
for long periods they are then referred to as nodules.
In severely affected patients, the nodules liquefy centrally so that uctuant cysts
are formed. In reality, the lesions are pseudocysts, as they have no epithelial lining. This type of severe acne is known as cystic or nodulocystic acne and can be
very disabling and disguring.
When the large nodules and cysts eventually subside, they leave in their wake
rm, brotic, nodular scars, which sometimes become hypertrophic or even
keloidal (Fig. 10.4a). The scars are often quite irregular and tend to form bridges
(Fig. 10.4b). Even the smaller inamed papules can cause scars and these tend to
be pock-like or are triangular indentations (ice-pick scars: Fig. 10.5).
There is a very rare and severe type of cystic acne known as acne fulminans
in which the acne lesions quite suddenly become very inamed. At the same time
the affected individual is unwell and develops fever and arthralgia. Laboratory
150
Acne
Figure 10.3 Acne papules.
(a)
(b)
Figure 10.4 (a) Nodular scars in acne. These lesions developed following the
resolution of inamed acne papules. (b) Hypertrophic scarring in a bridging pattern.
investigation reveals a polymorphonuclear leucocytosis and odd osteolytic lesions

in the bony skeleton. The cause of this disorder is not clear, although it has been
suggested that it is due to the presence of a vasculitis that is somehow precipitated
as a result of the underlying acne.
151
Figure 10.5 Pock scarring of acne.
SITES AFFECTED
Any hair-bearing skin can develop acne, but certain areas are much more
prone than others (Fig. 10.6). These acne-prone areas tend to have hair follicles
with small terminal hairs and larger sebaceous glands (sebaceous follicles). The
face and particularly the skin of the cheeks, lower jaw, chin, nose and forehead are
usually affected. The scalp is not involved, but the back of the neck, front of the
chest, the back and shoulders are all favoured areas for the development of
lesions.
In patients with severe acne, it is quite common for other areas to be affected,
including the outer aspects of the upper arms, the buttocks and thighs.
CLINICAL COURSE
For most of those affected, the disorder is annoying and may be troublesome, but
is not of enormous signicance because it is limited in extent and only lasts a few
months or at the most a year. For the unfortunate few, the condition is a disaster,
as it is disguring, disabling and persistent, with wave after wave of new lesions.
Although the natural tendency is for resolution, it is difcult to know in any individual patient when the condition will improve. The majority have lost their acne
by the age of 25 years, but some tend to have the occasional lesion for very much
longer. In some women there is a pronounced premenstrual are of their acne
some 710 days before the menses begin.
152
Acne
(a)
(b)
Figure 10.6 Diagram to show common sites of involvement due to acne on

(a) the front of the trunk and face, and (b) the back of the trunk.
Acne improves in the summertime and sun exposure seems to improve the
condition of many patients. However, the heat does not produce improvement
and, indeed, can make it much worse. Soldiers with acne in hot, humid climates
often become disabled by it suddenly worsening, with large areas of skin covered
by inamed and exuding acne lesions, and have to be evacuated home or to a
cooler climate.
EPIDEMIOLOGY
Some 70 per cent of the population develop some clinically evident acne at some
point during adolescence and early adult life, but perhaps only 1020 per cent
request medical attention for the problem. This proportion varies in different
parts of the world, depending on the racial mixture, the afuence and the sophistication of medical services.
153
Figure 10.7 Infantile acne.
Figure 10.8 Steroid acne. The lesions

tend to be more uniform in appearance
than in ordinary acne.
The variations in incidence in different ethnic groups have not been well characterized, although it does appear that Eskimos and Japanese suffer less from acne
than do Western Caucasians.
Onset is usually at puberty or a little later, although many patients do not
appear troubled until the age of 16 or 17 years. Men appear to be affected earlier
and more severely than women. Older age groups are not immune and it certainly
is not rare to develop acne in the sixth, seventh or even eighth decade.
Acne lesions sometimes appear on the cheeks and chin of infants a few weeks
or months of age and even a little later than that (Fig. 10.7). This infantile acne is
usually trivial and short lived, but can occasionally be troublesome.
SPECIAL TYPES OF ACNE

Acne from drugs and chemical agents
Androgens provide the normal drive to the sebaceous glands. It is the increased
secretion of these hormones that is responsible for the increased sebum secretion
at puberty. When given therapeutically for any reason, they can also cause an
eruption of acne spots.
Glucocorticoids, such as prednisolone, when given to suppress the signs
of rheumatoid arthritis or some other chronic inammation, can also induce
troublesome acne (Fig. 10.8). Why this should be so has never been adequately
154
Acne
Figure 10.9 Comedones and inamed

follicular papules from tar application.
Figure 10.10 Acne due to cosmetics.
explained. Glucocorticoids do not seem to increase the rate of sebum secretion, and the acne that results is curiously monomorphic in that sheets of acne
lesions appear (unlike ordinary acne) all at the same stage of development.
Interestingly, corticosteroid creams can, uncommonly, also cause acne spots at the
site of application.
Oil acne
Workers who come into contact with lubricating and cutting oils develop an acnelike eruption at the sites of contact, consisting of small papules, pustules and
comedones. This is often observed on the fronts of the thighs and forearms, where
oil-soaked overalls come in contact with the skin. A similar acneiform folliculitis
sometimes arises at sites of application of tar-containing ointments during the
treatment of skin diseases (Fig. 10.9).
Some cosmetics seem to aggravate or even cause acne. This is because they
sometimes contain comedo-inducing (comedogenic) agents, such as cocoa butter
and derivatives and some mineral oils, that can induce acne. This cosmetic acne is
less of a problem now that cosmetic manufacturers are aware of it (Fig. 10.10).
Chloracne
Chloracne is an extremely severe form of industrial acne due to exposure to complex

chlorinated naphthalenic compounds and dioxin. Epidemics have occurred after
155
industrial accidents such as occurred in Serveso in Italy, in which the population

around the factory was affected. The compounds responsible are extremely potent,
and lesions continue to develop for months after exposure. Typically, numerous
large, cystic-type lesions occur in this form of industrial acne.
Excoriated acne
This disorder is most often seen in young women. Small acne spots around the
chin, forehead and on the jaw line are picked, squeezed and otherwise altered by
manual interference. The resulting papules are crusted and often more inamed
than routine acne spots. Often, the patients have little true acne and the main cosmetic problem is the results of the labour of their ngers!
PATHOLOGY, AETIOLOGY AND PATHOGENESIS

Histologically, the essential features are those of a folliculitis with considerable
inammation. The exact histological picture depends on the stage reached at the
time of biopsy. Usually, it is possible to make out the remnants of a ruptured follicle. In the earliest stages, a follicular plug of horn (comedone) can be identied.
Later, fragments of horn appear to have provoked a violent mixed inammatory
reaction with many polymorphs and, in places, a granulomatous reaction with
many giant cells and histiocytes (Fig. 10.11). In older lesions, brous tissue is
deposited, indicating scar formation.
Figure 10.11 Pathology of inamed

acne papules showing a ruptured follicle
and a dense inammatory cell inltrate
composed predominantly of polymorphs.
156
Acne
What do we believe is the sequence of events? In the rst place, patients with
acne have a higher rate of sebum secretion rate (SER) compared to matched
control subjects and, furthermore, there is some correlation between the extent of
the increase in the SER and the severity of the acne.
Acne rst appears at puberty, at which time there is a sudden increase in the
level of circulating androgens. Eunuchs do not get acne, and the administration of
testosterone provokes the appearance of acne lesions. Sebaceous glands are predominantly androgen driven and few other inuences are as important.
Follicular obstruction also plays an important role. Comedones are early lesions
and microscopically it is commonplace to nd horny plugs in the follicular canals.
Changes have been described in the follicular epithelium suggesting that there is
abnormal keratinization at the mouth of the hair follicle.
Pathogenic bacteria are not found in acne lesions and are not involved in
the pathogenesis. It is possible, nonetheless, that the normal ora has a role
to play. The ora consists of Gram-positive cocci the micrococci (also known
as Staphylococcus epidermidis) and Gram-positive bacteria Propionibacterium
acnes. In addition, there are also yeast-like micro-organisms known as Pityrosporum
ovale. The Propionibacteria are microaerophilic and lipophilic, so that they are
ideally suited to living in the depths of the hair follicle in an oily milieu, and it is
not surprising that they increase in numbers during puberty when their food
supply, in the form of sebum, increases. The normal follicular ora may be
responsible for hydrolysing the lipid esters of sebum, liberating potentially irritating fatty acids. The constituents of sebum and of skin surface lipid (after bacterial hydrolysis) are given in Table 10.1.
How can these observations be linked? An acceptable hypothesis is set out in
Figure 10.12, in which it is suggested that the important inammatory lesions of
acne are the result of follicular rupture.
Table 10.1 Main

constituents of sebum and
skin surface lipid
Sebum
Triglycerides
Cholesterol ester
Squalene
Wax esters
Skin surface lipid
Sebum lipids
Fatty acids
Monoglycerides
Diglycerides
TREATMENT
Typically, unasked for advice from the family is given in which the sufferer
is blamed in one way or another for having the disorder and accused of doing
too much of one thing or not enough of the other. Consequently, many forms
of familial or folk treatments seem to be more in the nature of punishments
than anything else. Dietetic and social restrictions are typical, as is more frequent
washing, which is another tactic adopted by well-meaning but misguided family
and friends.
Fortunately, most acne patients improve spontaneously after a few months.
Those who do not, nd their way to the pharmacist and purchase preparations
containing benzoyl peroxide or other antimicrobial compounds, or sulphur or
salicylic acid. Many with milder degrees of acne will be helped by these medications. It is only those with resistant, recalcitrant and more severe types of acne
who reach the physician. Perhaps only 10 per cent of those with clinical acne in
the UK see their practitioner.
157
Comedone
Irritation of follicular wall
Increased lipolysis
Ruptured wall
Follicle lumen
Increased microflora
Inflammation
Increased sebum secretion
Sebaceous gland
Figure 10.12 Diagram to show suggested events in the pathogenesis of acne.
Basic principles
Treatment may be aimed at:
reducing the bacterial population of the hair follicles to cut down the hydrolysis of lipids (antimicrobial agents)
encouraging the shedding of the follicular horny plugs to free the obstruction
(comedolytic agents)
reducing the rate of sebum production, either directly by acting on the sebaceous glands or indirectly by inhibiting the effects of androgens on the sebaceous
glands (anti-androgens)
reducing the damaging effects of acne inammation on the skin with antiinammatory agents (Table 10.2).
General measures
Patients with acne are often depressed and may need sympathetic counselling and
support. There is no evidence that particular foodstuffs have any deleterious effect
or that washing vigorously will help remove lesions. These and other myths
should be dispelled and replaced with a straightforward explanation of the nature
of the disorder, its natural history and treatment.
Topical treatment
Currently, the most popular form of topical preparation is a gel, cream or alcoholbased lotion.
158
Acne
Table 10.2 Treatments for acne

Topical
Antimicrobial
Oral
Comedolytic
Antimicrobial
Sebum suppressive
Benzoyl peroxide
Tretinoin
Tetracycline
Isotretinoin
Tetracycline
Isotretinoin
Minocycline
Erythromycin
Adapalene
Doxycycline
Cyproterone and
ethinylestranol
Erythromycin
Spironolactone
Clindamycin
Azelaic acid
Topical retinoids
These are comedolytic. Tretinoin-containing preparations are not bactericidal,
but are nonetheless effective. The cis-isomer of tretinoin isotretinoin is also
used successfully for the treatment of acne. Adapalene is a recently introduced,
effective topical retinoid that is also useful.
The side effects from the use of retinoid preparations include some pinkness
and slight scaling of the skin surface, especially in fair, sensitive-skinned individuals. For the most part, this dryness of the treated area is tolerable and decreases
after continual usage. It is less marked with adapalene.
Sulphur (as elemental sulphur 210 per cent) has been used traditionally as a
treatment for acne. It seems to be helpful for some patients, but has dropped out
of fashion. Its efcacy probably depends on both its antimicrobial action and its
comedolytic activity.
Other agents employed to remove blackheads include abrasive preparations.
These contain particles of substances such as aluminium oxide or polyethylene
beads, which literally abrade the skin surface and liberate the comedones.
Topical antibiotics
Erythromycin (12 per cent) and clindamycin (2 per cent) preparations are quite
effective for mild and moderate types of acne. Tetracycline preparations (2 per
cent) are slightly less effective. Fortunately, these antibiotics have a low tendency
to sensitize and are not often responsible for allergic contact dermatitis, although
they may cause a minor degree of direct primary irritation.
Other antimicrobial compounds
Bacterial resistance to erythromycin frequently develops and may prove a problem in the future.
Systemic treatment
Antibiotics
Tetracyclines
Systemic tetracyclines have been the sheet anchor of treatment for moderate and
severe acne for many years. Patients with many papular lesions involving several
159
sites are suitable for systemic tetracyclines. It is usual to start treatment with a
dose of 250 mg t.i.d. or 6-hourly, and then, when there is a response, to reduce the
dose to that required to keep the patient free of new lesions. The improvement
usually begins 48 weeks after starting treatment and continues over the next 23
months. Some 70 per cent of patients can be expected to improve on this regimen.
Treatment may have to be maintained for several months or, exceptionally, even
longer. With tetracycline and oxytetracycline, the drug should be given 30 minutes
before a meal to prevent interference with absorption. The newer minocycline and
doxycycline are given in smaller doses (50 mg or 100 mg) once or twice per day
and their absorption does not seem to be affected by food.
Side effects with the tetracyclines are few and not usually serious. Gastrointestinal
discomfort and diarrhoea occasionally occur. Photosensitivity was mainly a problem with older, now no longer used, analogues. Fixed drug eruption and, rarely,
other acute drug rashes develop. Minocycline can cause a dark-brown pigmentation
of the skin or acne scars or acral areas on the exposed part of the skin after longcontinued use in a small number of patients.
Tetracyclines must not be given to pregnant women, as they are teratogenic,
and must not be given to infants, as they cause a bone and tooth dystrophy in
which these structures become deformed and discoloured.
Erythromycin
The efcacy of erythromycin in acne is similar to that of the tetracyclines. The
starting dosage is 250 mg 6-hourly for the rst few weeks, with reduction after a
response has begun. Subsequently, management is as for the tetracyclines. Side
effects are usually minor and restricted to nausea.
Other antibiotics and antimicrobials
Clindamycin, the quinolines and the sulphonamides are other drugs that have
been used systemically for acne. None is more effective than the tetracyclines, but
they may be suitable for patients who are either intolerant or who no longer
respond to the tetracyclines or erythromycin. Side effects are more common and
sometimes of a serious nature (e.g. blood dyscrasias).
Isotretinoin (13-cis-retinoic acid)
The large majority of patients with acne will respond to topical or some combination of topical and systemic drugs. However, some severely affected patients
may not, and for them there is another drug that can offer relief. This agent is the
retinoid isotretinoin (the same cis-isomer of tretinoin used topically). It reduces
sebum secretion by shrinking the sebaceous glands and may also alter keratinization of the mouth of the hair follicle and have an anti-inammatory action.
It is given in a dose of 0.51.0 mg/kg body weight per day, usually for a
4-month period. The response after a few weeks is to inhibit new lesions in more
than 80 per cent of patients. Patients with many large cystic lesions affecting the
trunk as well as the head and neck region take longer to respond and may need
more than one 4-month course.
160
Acne
Unfortunately, toxic side effects are frequent. They range from the trivial, of
which the most common is drying and cracking of the lips, to the very serious,
which include teratogenicity, hepatotoxicity, bone toxicity and a blood lipidelevating effect. The teratogenic effects are very worrisome, as the acne age group
is almost identical to the reproductive age group. The effects on the fetus include
facial, cardiac, renal and neural defects and are most likely to arise if the drug is
taken during the rst trimester. Some 3050 per cent of pregnancies during which
the drug was taken have been affected. Because of this, it is strongly recommended
that if it is planned to prescribe isotretinoin for women who can conceive, effective contraceptive measures must also be planned and used during and for 2 months
after stopping the drug.
Hepatotoxicity is rare, although a small rise in liver enzymes is common. A rise
in triglycerides and cholesterol, such that the ratio of very low-density lipoproteins to high-density lipoproteins is increased, regularly occurs, and overall there
is a 30 per cent rise in lipid levels. This is not likely to be a problem for most
patients with acne, but may be for older patients. The same is true for the bone
toxicity. A variety of bone anomalies have been described, including disseminated
interstitial skeletal hyperostosis and osteoporosis, but these are not likely to be a
problem for acne subjects. The drug has also been accused of causing severe
depression, leading to suicide in some cases. The evidence for this is not strong, as
severe acne patients are often depressed before starting treatment. Because of the
toxicities of this important drug it can only be prescribed from hospitals in the UK.
Case 9
Julia was 15 when she started to develop embarrassing acne. She had noticed
that her skin had been very greasy skin for the last few months. New spots
appeared every day and she spent hours in front of the mirror trying to squeeze
out blackheads and get rid of pustules. It made her quite depressed and matters
were made worse by her parents telling her that she didnt wash her face enough
and that going to discos didnt help her skin. Fortunately, her GP was more
sympathetic and prescribed a benzoyl peroxide preparation and oral doxycycline,
which made a big improvement after about 6 weeks.
Anti-androgens
Anti-androgens inhibit androgenic activity and reduce sebum secretion. Currently,

only one anti-androgen preparation is available Dianette. This is a mixture of an
anti-androgen, cyproterone acetate (2 mg), and an oestrogen, ethinyl oestradiol
(35 g). It is a central anti-androgen, blocking the pituitary drive to androgen secretion. It also suppresses ovulation and acts as an oral contraceptive. It is not suitable
for men because of its feminizing properties. It improves acne after some 68 weeks
of use, but is not as effective as isotretinoin. It is associated with a number of minor
side effects, essentially those associated with taking oral contraceptives.
Spironolactone, the potassium-sparing diuretic, has also been found to have
anti-androgenic effects and has occasionally been used as a treatment for acne.
161
Rosacea
DEFINITION
Rosacea is a chronic inammatory disorder of the skin of the facial convexities,
characterized by persistent erythema and telangiectasia punctuated by acute
episodes of swelling, papules and pustules.
CLINICAL FEATURES
Sites affected
The cheeks, forehead, nose and chin are the most frequently affected areas, making a typical cruciate pattern of skin involvement (Fig. 10.13). The exures and
periocular areas are conspicuously spared. Uncommonly, the neck and the bald
area of the scalp in men are also affected. Sometimes only one or two areas are
affected, and this makes diagnosis quite difcult.
The lesions
The most characteristic physical sign is that of persistent erythema, often accompanied by marked telangiectasia (Fig. 10.14). The disorder may not progress
Figure 10.13 Typical rosacea with

involvement of the cheeks, forehead
and chin.
Figure 10.14 Erythema and

telangiectasia in rosacea.
162
Rosacea
(a)
(b)
Figure 10.15 (a) and (b)

Papules of facial skin in
rosacea.
beyond this erythemato-telangiectatic state but, even if it does not, the bright red
face causes considerable social discomfort and often marked depression. Such
patients also complain of frequent ushing at the most trivial stimuli.
Superimposed on this persistent background of erythema are episodes of
swelling and papules, which develop for no very obvious reason (Fig. 10.15). The
papules are a dull red, dome shaped and non-tender, in contrast to acne, in which
they tend to be irregular and tender. Pustules also occur, but are less frequent than
in acne; blackheads, cysts and scars do not.
Any red rash of the face may be confused with rosacea (Table 10.3).
Papular rashes of the face seem to cause most problems. Acne occurs in a
younger age group and is usually distinguished by the greasy skin, comedones and
scars as well as lesions on sites other than the face. However, in some patients, the
presence of persistent erythema can make differentiation quite difcult. Perioral
dermatitis (see page 168) should not be difcult to differentiate, as this disease is
mainly distributed around the mouth and there is no background of erythema.
Systemic lupus erythematosus may supercially resemble rosacea, become of the
symmertrical buttery erythema but there are no symptoms of systemic disease
in rosacea. Dermatitis of the face (including seborrhoeic dermatitis) is marked by
scaling, which is not characteristic of rosacea.
Polycythaemia rubra vera gives the face a plethoric appearance. The carcinoid syndrome is characterized by reddened areas on the face in the same
163
Table 10.3 Differential diagnosis of rosacea

Disorder
Positive discriminants
Skin disorders
Acne
Scars, seborrhoea, cysts, back and chest involvement
Scaling involvement of exures
Perioral dermatitis
Micropapules, perioral and paranasal involvement
Systemic disorders
Systemic lupus
erythematosus
Rash on light-exposed areas, arthropathy, positive

antinuclear factor, haematological ndings
Dermatomyositis
Mauve-lilac rash around the eyes, with swelling, rash

on backs of ngers, muscle tenderness, pain and
weakness, positive laboratory ndings
Carcinoid syndrome
Marked telangiectasia, ushing attacks, hepatomegaly
Polycythaemia rubra vera
General facial redness and suffusion, possibly

hepatosplenomegaly
distribution as in rosacea, but the condition is accompanied by severe systemic

symptoms.
Dermatomyositis is characterized by mauvish erythema around the eyes, but
the pain, tenderness and weakness of limb girdle muscles should quickly distinguish this disease.
COMPLICATIONS
Rhinophyma
This occurs mainly in elderly men, although it occasionally occurs in women too.
The nose becomes irregularly enlarged and craggy, with accentuation of the pilosebaceous orices (Fig. 10.16). At the same time, the nose develops a mauve or
dull-red discoloration with prominent telangiectatic vessels coursing over it (Fig.
10.17). Popular names for this include whisky-drinkers nose and grog blossom,
but it is not due to alcoholism.
Lymphoedema
Persistent lymphoedema is another unpleasant, though uncommon, complication

of rosacea seen predominantly in men. The swollen areas are usually a shade of
red and may persist when the other manifestations of rosacea have remitted.
Ocular complications
Some 3050 per cent of patients with acute papular rosacea have a blepharoconjunctivitis. This is usually mild, but some patients complain bitterly of soreness and
164
Rosacea
Figure 10.16 Severe, irregular, craggy

enlargement of the nose due to
rhinophyma.
Figure 10.17 Rhinophyma with

prominent telangiectasia.
grittiness of the eyes. Some of this may be the result of keratoconjunctivitis sicca,
which appears to be quite common in rosacea. Styes and chalazion are also more
common in rosacea. Keratitis is a rare, painful complication occurring in men, in
which a vascular pannus moves across the cornea, producing severe visual defects.
NATURAL HISTORY
Rosacea tends to be a persistent disease and the tendency for patients to develop
episodes of acute rosacea remains for many years after appropriate treatment has
calmed down an attack.
EPIDEMIOLOGY
Rosacea is quite a common disorder, but its exact prevalence is not known and
varies in different communities. The disorder is essentially one of fair-skinned
Caucasians. It seems particularly common in Celtic peoples and in individuals
from northwest Europe. It is only occasionally seen in darker-skinned and Asian
skin types and is rare in black-skinned individuals. It has been claimed that it is
more common in women, but this may be merely a reection of the disorder
being of more concern to women.
165
Figure 10.18 Pathology of rosacea showing marked

telangiectasia, dermal oedema and marked solar
degenerative change.
Figure 10.19 Pathology of rosacea showing

inammatory cell inltrate with many lymphocytes
and giant cells around blood vessels.
PATHOLOGY
There is no single pathognomonic feature, but there is a characteristic constellation of features in histological sections that makes skin biopsy a useful test when
the clinical diagnosis is uncertain. A feature common to all rosacea skin samples
is the presence of disorganization, solar damage, oedema and telangiectasia in the
upper dermis (Fig. 10.18). When there are inammatory papules, the blood vessels are encircled by lymphocytes and histiocytes, amongst which giant cell systems are sometimes found (Fig. 10.19). In rhinophyma, apart from abnormalities
in the brous dermis and inammation, there is also marked sebaceous gland
hyperplasia.
AETIOLOGY AND PATHOGENESIS

The cause of rosacea remains uncertain. Historically, dietary excess, alcoholism,
gastrointestinal inammatory disease, malabsorption and psychiatric disturbance
have all been though to be responsible, but controlled studies fail to implicate
these agencies. The role of the mite Demodex folliculorum, a normal commensal
of the hair follicle, is also unclear. Although it is found in increased numbers in
rosacea, this increase may result from the underlying disorder in which there is
follicular distortion and dilatation.
Environmental trauma appears to play an important role in the development
of rosacea. The disorganization of upper dermal collagen, the excess of solar elastotic degenerative change and the predominance in fair-skinned types all point to
the importance of damage to the upper dermis. Inadequate dermal support to the
vasculature, which then dilates, allows pooling of the blood in this site. This pooling may then itself compromise endothelial function and ultimately result in
episodes of inammation (Fig. 10.20).
166
Rosacea
Cold wind
Solar UV
Inherently
individual
susceptible
(Erythema and
telangiectasia)
DERMAL
DYSTROPHY
TELANGIECTASIA
Heat
Damage
to dermis
Damage to skin
sustained in acne
Pooling of blood
Endothelial damage
Inflammation
(Papules and
pustules)
Leakage of potentially
inflammatory substances
(swelling)
Figure 10.20 Possible sequence of events in rosacea.
Depressed delayed hypersensitivity and deposits of immunoprotein in facial

skin have also been reported, suggesting that the immune system is involved in the
pathogenesis.
TREATMENT
Systemic treatment
The acute episodes can be calmed with systemic tetracycline, erythromycin or

metronidazole, using the full antibacterial dosage until the condition improves
and then a dose sufcient to maintain improvement. Initial improvement usually
occurs within the rst 34 weeks of treatment. It would be typical for a patient to
start tetracycline 250 mg 6-hourly for 3 weeks and then receive the drug three
times daily for a further 3 or 4 weeks. At that time, reduction to twice-daily dosage
would be made and maintained until stopping (perhaps at 10 or 12 weeks) did not
result in the appearance of further papules. Minocycline or doxycycline 50 mg
once or twice per day is more convenient. Erythromycin is also effective and the
same dose regimen applies as for tetracycline. Metronidazole is not often given
because of its side-effect prole. It has a disulram-like effect, causing alcohol
intolerance. Other side effects include nausea and blood dyscrasias.
Isotretinoin may help some patients, particularly those who have rhinophyma,
as it has been shown that it reduces the size of the enlarged nose as well as reducing the numbers of papules present.
Topical treatments
Topical corticosteroids are denitely contraindicated. Although they may suppress

the inammatory papules, they tend to make the face redder and more telangiectatic,
167
Figure 10.21 Intense erythema and

telangiectasia in rosacea due to
mistreatment with potent topical
corticosteroids.
presumably because they cause even more upper dermal wasting and exposure of the
subpapillary venous plexus (Fig. 10.21).
Facial skin may be sore and uncomfortable in rosacea and the use of emollients
can give some symptomatic relief as well as discouraging the use of topical corticosteroids! Sunscreens are of help in preventing further solar damage. Preparations
of 0.751.5 per cent metronidazole in either a cream or gel base seem capable of
reducing the inammatory papules as efciently and as quickly as systemic tetracycline. Topical azelaic acid (20 per cent) has also been shown to be effective.
How systemic antibiotics, or metronidazole, systemic or topical, achieve their
effects in rosacea is not clear. Treatment with the pulsed dye laser can greatly
improve the erythema in rosacea.
Perioral dermatitis
DEFINITION
Perioral dermatitis is a not uncommon, inammatory disorder of the skin around
the mouth, characterized by the occurrence of micropapules and pustules.
CLINICAL FEATURES
Many minute, pink papules and pustules develop around the mouth, sparing the
area immediately next to the vermillion of the lips (Fig. 10.22). Lesions sometimes
168
Summary
Figure 10.22 Perioral dermatitis. There

are many tiny papules around the mouth.
involve the nasolabial grooves and, in severely affected patients, also affect the skin
at the sides of the nose. There is no background of erythema, distinguishing the
condition from rosacea.
The condition develops insidiously and seems to persist until treated. Recurrence is uncommon.
Perioral dermatitis is most common in young women aged 1525 years, being
quite rare in men and in older women. Its exact incidence is unknown, but it is of
interest to know that it was rst recognized in the late 1960s, seemed quite common in afuent Western communities in the 1970s and then appeared to become
less frequently observed in the 1980s, reappearing once again in the 1990s. Many
have suspected that the use of topical corticosteroids is to blame. Patients usually
respond to a course of systemic tetracycline as for rosacea for a period of 48
weeks. No topical treatments are indicated.
Summary
Acne occurs in most individuals during adolescence.
It is characterized by increased sebum secretion
and the formation of comedones.
Comedones are dilated hair follicles containing
horny plugs, the tips of which are black due
to melanin (blackheads). These blocked follicles
often leak and may rupture, causing inammatory
papules and pustules, and when several are
involved, give rise to acne cysts (pseudocysts in
reality) form. The inammation causes tissue
destruction and hypertrophic, keloidal, pock-like
or ice-pick scars.
The face (cheeks, chin, forehead, lower jaw and
nose), back of the neck, back, shoulders and chest
are the commonest sites involved.
The disorder is not troublesome for most, but
discomforting and embarrassing for many, and a
complete disaster in a few. It may only last a few

months, but can persist for years. Older subjects
are not immune and mild acne occasionally occurs
in infants. Oils and greases can aggravate or even
cause acne.
The rate of sebum secretion is increased by the
surge in testosterone levels at puberty.
Propionibacterium acnes a major component of
the normal follicular ora is microaerophilic and
lipophilic. These bacteria greatly increase in
numbers in the dilated and plugged follicle. The
inammation of acne may well be caused by the
leakage of follicular content and bacterial
degradation products, including irritating fatty acids,
into the dermis.
Only a small proportion of acne sufferers (perhaps
10 per cent) are seen by their general practitioners.
169
The basic principles of treatment are to reduce the

bacterial population, encourage shedding of
follicular plugs (comedolysis), reduce the rate of
sebum production and reduce the degree of
inammation.
Topical retinoids (tretinoin, isotretinoin and
adapalene) are comedolytic agents. They are quite
effective but irritating. Topical antibiotics
(erythromycin, clindamycin and tetracycline) are
quite useful, as are preparations of benzoyl
peroxide, which are both antimicrobial and
comedolytic.
When the acne is severe, systemic treatments
are needed. Systemic tetracyclines (oxytetracycline,
doxycycline or minocycline) and erythromycin
are most often used. They may need to be
given over some months. Systemic isotretinoin
is the most effective agent for severe acne,
but is capable of causing many adverse side
effects, including fetal deformities if given to
pregnant women. An anti-androgen preparation
containing cyproterone acetate and ethinyl
oestradiol is also used in female patients and
may be helpful.
Rosacea may be dened as a chronic
inammatory disorder of the convexities of facial
skin, characterized by persistent erythema and
telangiectasia, punctuated by acute episodes of
swelling, papules and pustules. It is quite
common, affecting mainly fair-complexioned

adults aged 3060.
The cheeks, chin, nose and forehead are mainly
affected, but the neck and the bald scalp of
men my occasionally be involved. The papules
are unlike those of acne, being non-tender
and dome shaped. Blackheads, cysts and
scars are not seen. Rhinophyma (irregular
nasal swelling), keratitis and persistent
lymphoedema of facial skin are complications
seen mainly in men.
Rosacea needs to be distinguished from acne,
seborrhoeic dermatitis and other disorders with
reddened facial skin, such as lupus erythematosus
and dermatomyositis.
The cause is unknown, but the occurrence in
fair-skinned individuals on light-exposed sites and
the presence of a marked degree of solar damage
histologically suggest that photodamage plays a
major role.
The condition tends to persist, but acute episodes
usually respond to oral tetracycline or erythromycin
or topical metronidazole. Topical corticosteroids
tend to aggravate the disorder.
Perioral dermatitis is a disorder in which
micropapules and papulopustules occur
periorally and paranasally in young women.
It responds to oral tetracycline but not to topical
preparations.
170
C H A P T E R
11
Wound healing
and ulcers
171
Venous hypertension, the gravitational syndrome and venous ulceration
173
177
178
Neuropathic ulcers
179
180
182
Summary
182

Wound healing is a complex and fundamental activity of all damaged body structures. The same principles underlie the healing of cuts, abrasions, ulcers and areas
damaged by chemical attack, invasion by micro-organisms or immune reactions.
Healing of the skin damaged by a physical insult may be divided into:
an immediate haemostatic phase,

an early phase of re-epithelialization,
a later phase of dermal repair and remodelling (Fig. 11.1).
It is hoped that better understanding of the complex interactions and their

controls will result in new techniques and substances for the treatment of nonhealing wounds. Persistent non-healing ulcers of the skin are very common and
cause much unhappiness, disablement and economic loss.
FACTORS IMPORTANT IN THE HEALING OF WOUNDS
Adequate supplies of nutrients and oxygen are required for efcient healing;
when the blood supply is compromised, healing is delayed. Vitamin C and zinc
deciencies are amongst the deciency states also associated with delayed
wound healing.
171
Wound healing and ulcers
E
FC
012 hours
DCT
BV
(a)
ME
F, MF, M
GT
12 hours4 days
BV
SC
(b)
BV
DC
F, M
410 days
(c)
Figure 11.1 The sequence of events after incisional

wounding of the skin. (a) 0 to 12 hours. Initially, the
small blood vessels constrict and then platelets plug the
endothelial gaps. The extravasated blood clots form a
temporary plug for the wound. White cells accumulate at
the interface between the damaged and the normal
tissue. (b) 12 hours to 4 days. After some 1824 hours,
epidermal cells actively move on to the surface of the
defect. Epidermal cells at the sides of the wound divide
some hours later to make good the loss. Epidermis also
sprouts from the cut ends of the sweat coils and hair
follicles. After 24 days, new capillaries start to sprout
and vascularize the granulation tissue in the wound
cavity. Damaged connective tissue is destroyed and
removed by macrophages, and new collagen is secreted
by broblasts. Myobroblasts are broblastic cells that
develop the power to contract and are responsible for
wound contraction. (c) 4 to 10 days. Between 4 and 10
days after wounding, the wound cavity has become
covered with new epidermis, whose stratum corneum
does not possess normal barrier efciency until the end
of this period. The granulation tissue has been replaced
by a new dermis whose collagenous bres are not yet
orientated. In the later stages, remodelling takes place
so that orientation of the dermal collagenous bundles to
the original lines of stress occurs. Scar formation occurs
when there has been signicant damage to the dermis.
The epidermis ultimately develops a normal prole and
the vasculature is also restored to normal contractility.
E epidermis; DCT dermal connective tissue;
BV blood vessel; FC brin clot; ME migrating
epidermis; F broblasts; MF myobroblasts;
M macrophages; DC dermal collagen;
GT granulation tissue; SC sweat coil.
Persistent infection with tuberculosis, Mycobacterium ulcerans or syphilis

causes ulcerative conditions directly due to an infection. Any ulcerated area
becomes contaminated by microbes in the environment and often this secondary infection causes further tissue destruction.
In some uncommon congenital disorders, there is delayed wound healing
because the orderly sequence is disrupted. These disorders include factor XIII
deciency, in which there are abnormalities of cross-linking of bronectin and
172
Venous hypertension, the gravitational syndrome, venous ulceration
Table 11.1 Common causes of persistent ulcers

Condition
Aetiopathogenesis
Site(s)
Features
Venous ulcer
Venous incompetence, venous

hypertension, tissue oedema
and inammation
Medial malleolus commonly

and ankle nearby
Sloughy; signs of venous

hypertension
Ischaemic ulcer
Atherosclerosis in most
instances
Mostly feet and lower legs
Painful; occurring in
atrophic skin
Ulcer due to vasculitis
Polyarteritis nodosa and

HenochSchnlein purpura
are examples of vasculitic
disorders causing ulcers
Commonly on the legs,

but anywhere can be
affected
Lesions often start as

purpuric patches or
nodules
Neuropathic ulcer
Inadvertent repetitive injury

because of sensory
loss common in diabetes
and leprosy
Soles of feet particularly
Deeply perforating ulcers

are characteristic
Decubitus ulcer
Pressure on skin of dependent

parts in unconscious or
paralysed patients
Sacrum ischial region,

heels, scapular region,
back of head, elbows
Deep sloughy ulcers
collagen, protein C deciency and Marfans syndrome, in which there are

abnormalities of dermal connective tissue repair.
The common causes of persistent leg ulcers are given in Table 11.1.
Venous hypertension, the gravitational syndrome

and venous ulceration
VENOUS HYPERTENSION
Epidemiology
It has been estimated that between 0.5 and 1.0 per cent of the population of
the UK suffers from venous ulcers at any one time. The disorder is most often seen
after the age of 60 and women are more often affected particularly the multiparous. It is mostly a problem of the poor and underprivileged. Interestingly, it
does not occur with equal prevalence in all racial groups, for example it is rare in
Arabic peoples.
When venous return is impeded, hypertension develops in the venous circulation

behind the blockage. This results in the development of dilatation of the small
173
(b)
(a)
Abnormal leaky valves

allowing backflow
Valves
Muscle pump
Muscle
pump
Figure 11.2 (a) Normal

venous return from the legs.
(b) Venous hypertension
due to leaky valves.
V varicosities
T telangiectatic vessels
V
V
T
T
venules and, because of the changed pressure relationships at the tissue level,
exudation into the tissues and oedema.
This situation arises in the leg veins when the venous valves are faulty. Blood
leaks back through these faulty valves after being pushed towards the heart by the
muscle pump of the lower leg (Fig. 11.2). The valves become faulty because venous
thrombosis destroys them, but are sometimes congenitally faulty. Venous hypertension caused by the back pressure is transmitted back to the smaller supercial veins
via perforating veins, causing varicosities and telangiectasia (Figs 11.3 and 11.4).
The increased pressure at the venous end of the capillaries leads to transudation and the deposition of brin perivascularly (Fig. 11.4). The tissue oedema and
Figure 11.3 The results of venous hypertension the
gravitational syndrome. Note the pigmentation,
telangiectasia and visible varicosities.
Figure 11.4 Pathology of venous hypertension showing

thickening and increase in number of small blood
vessels in the dermis.
174
Venous hypertension, the gravitational syndrome, venous ulceration
the brin cause hypoxaemia, inammation and eventually brosis. Extravasation

of red blood cells results in the deposition of haemosiderin pigment in dermal
macrophages, imparting a brownish pigmentation to the skin.
The small blood vessels thicken and proliferate in response to the hypoxaemia,
giving rise to a characteristic histological picture that can, because of the vascular
proliferation, in extreme cases resemble Kaposis sarcoma (see page 223).
Clinical features
The earliest signs are of pitting ankle oedema and distended supercial long veins
in the lower leg. A network of smaller veins appears around the foot. Later, brownish discoloration develops and the swelling becomes rmer and eventually woody
to the touch because of the brosis (Fig. 11.5). Ulceration may occur at any stage,
usually after a minor injury that does not heal but steadily enlarges.
Venous ulcers are usually seen around the medial malleolus, but sometimes
occur elsewhere and are usually single (Figs 11.6 and 11.7). Large ulcers may
encircle the leg. The base of venous ulcers is often lined by a yellowish grey slough
and the edges are for the most part ush with the skin surface and irregular in
outline (Fig. 11.7).
Course and prognosis
Many ulcers heal, but may take many months to do so. Unfortunately, when healed,
they tend to recur. Some never completely heal, but run a remittent course.
Figure 11.5 Venous hypertension. Note the

pigmentation and appearance of the skin, suggesting
that it is bound down to underlying tissues.
Figure 11.6 Typical venous ulcer.

175
Figure 11.7 Venous ulcer with exudative

base and sloughy appearance of
surrounding skin.
Complications
Infection. They may become severely infected with either Gram-positive cocci
or Gram-negative micro-organisms.
Bleeding. Uncommonly, large veins may rupture and cause severe bleeding.
Eczema. An eczematous rash is common in patients with venous ulcers. In twothirds to three-quarters of patients, this is the result of allergic contact hypersensitivity to one of the medicaments used in treatment (e.g. neomycin, Vioform)
or one of the constituents of the vehicle (e.g. lanolin or ethylene diamine; see
page 123). In a few patients, autosensitization is thought to occur in which sensitivity to the breakdown products from the ulcerated area develops. Venous
eczema develops on the opposite leg, the lateral aspects of the thighs and the
upper arms and at other scattered sites.
Malignant change. Rarely, squamous cell carcinoma or basal cell carcinoma
develops in long-standing lesions.
Anaemia. Patients with persistent ulcers often develop a normochromic
anaemia and are generally debilitated. The loss of protein, salts and metabolites
in the exudates from the open area and absorption of products of tissue degradation and bacterial activity are probably responsible.
Treatment
The most useful approach is to try to improve venous drainage by:
Elevation of the legs above the head level at regular periods during the day (two
1-hour periods).
176
Compression bandaging, using either specially made elasticated stockings or

elasticated bandage. The pressure should be graduated so that it is greatest at
the ankle and least at the top of the bandage or stocking. Care must be taken to
ensure that there is no restriction of arterial blood supply.
Gentle regular exercise to ensure that the calf muscle pump assists in the
return of blood towards the heart.
Weight reduction.
Dressings
Non-adherent, non-toxic, non-sensitizing dressings should be used. Antibacterial
properties are also helpful. In addition, dressings should ideally be partially
absorptive and semi-occlusive to provide high humidity at the wound interface.
This promotes re-epithelialization. Hydrocolloid dressing materials, gels and some
paste bandages are suitable. Tulle dressings are also acceptable.
Topical treatments
The ulcer base may be irrigated with normal saline, dilute potassium permanganate solution or very weak chlorhexidine or hypochlorite solutions. Many traditional agents are damaging to the healing tissues and must not be left in contact
with the wound surface.
Surgery
Split skin fragment grafts may speed ulcer healing in the short term, but may not
improve the long-term outlook. Grafts with skin cultivated in vitro have also been
used with some success. Surgical management of the incompetent veins may assist
in some cases.
Case 10
Andrew was fed up. At the age of 79 he had been all through the 193945 war
without serious injury, but now he had a large, non-healing ulcer on his right ankle
(just above the medial malleolus). It hurt quite a bit, but he found that the oozing
and unpleasant smell it caused were even more troublesome. Andrew had
the ulcer for 3 months and wanted to get rid of it. His ankles were swollen and
there was some brown discoloration around both of them. The dermatologist told
him that the ulcer was due to the veins not draining the blood back from his legs
efciently. Andrew was told to lose weight, to use elasticated stockings and to
elevate his legs for at least 2 hours per day. Arrangements were made for the
district nurse to dress his ulcer three times a week with a non-adherent dressing,
and he was happy when it started to heal a few months later.
Ulceration due to ischaemia is a common clinical problem, though less often seen
than that due to venous hypertension.
177
PATHOGENESIS
Atherosclerosis accounts for the majority of cases. This affects major vessels and
mostly occurs gradually, so that the ulceration occurs in chronically ischaemic
skin. Embolism may cause acute ulceration and gangrene.
Diabetes predisposes to atherosclerosis and impairs wound healing, making
the problem particularly common. Disease of the medium-sized or small blood
vessels also causes ulceration in allergic vasculitis.
It should be noted that ischaemic and venous ulcers are often due to both
processes, although one predominates, as venous hypertension and atherosclerotic arterial disease are common and often coexist.
CLINICAL FEATURES
Ischaemic ulcers are painful and irregular, occurring anywhere around the feet or
lower legs. The skin around the ulcerated area is pale, cool, smooth and hairless.
Light pressure with a nger on the skin makes it a deathly white and the pink
colour takes longer to return than normal.
TREATMENT
Medical treatment is only helpful in the earliest and mildest cases. Keeping the
affected part warm and protecting it from injury are important. Peripheral vasodilating drugs are only marginally useful (e.g. pentaerythritol tetranitrate, glyceryl
trinitrate, isosorbide dinitrate, nifedipine). Drugs promoting vascular ow, such
as hydroxyethyl rutosides and oxpentifylline, are rarely helpful.
Sympathectomy removes sympathetic vasoconstrictor tone and causes some
vasodilatation, but rarely results in much clinical benet. Of greater help is
endarterectomy, either by open surgical technique or percutaneously, or arterial
grafting.
These lesions are the result of localized ischaemia due to long-continued pressure
on skin at contact points with bedclothes and occurs in the unconscious or paralysed patient.
CLINICAL FEATURES
Classically, ulcers occur over the sacrum or ischial regions (Fig. 11.8), the heels,
the back of the head, the scapulae and the elbows. The ulcers are often deeply
penetrating and sloughy.
178
Neuropathic ulcers
Figure 11.8 Ischial ulceration in a paralysed patient.
Figure 11.9 Neuropathic ulcer.
PROPHYLAXIS AND TREATMENT

Meticulously careful nursing, with regular turning and the use of sheeps eece
bedding or ripple mattresses that constantly change pressure points, helps prevent decubitus ulcers. Maintenance of nutrition and general health as much as
possible will also aid in the prevention of pressure sores.
The individual ulcerated lesions need cleaning with non-toxic antibacterial
solutions and dressing with non-adherent, non-toxic dressings (as for venous
ulcers).
Neuropathic ulcers
Neuropathic ulcers result from repeated, inadvertent injury to hypoanaesthetic or
anaesthetic areas of skin subsequent to nerve injury. They are most often seen in
diabetes in the UK and Europe, but leprosy is a common cause in some parts of
the world.
CLINICAL FEATURES
These lesions may be very deeply penetrating. They occur mostly on the soles of
the feet, but may also be seen elsewhere on the foot (Fig. 11.9).
TREATMENT
Local treatment is unlikely to make any impact on these lesions. The only effective treatment is to protect the damaged area with padding and appliances and,
if possible, to restore sensation to the anaesthetic area.
179

PYODERMA GANGRENOSUM
This is a rare, serious ulcerative disorder that is often due to serious underlying
systemic disease.
Clinical features
Usually, an acutely inamed, purplish nodule rapidly becomes an ulcer, which

then spreads with frightening speed (Fig. 11.10). The ulcer characteristically has
bluish-mauve, undermined margins. Such ulcers may be dinner plate sized or
even larger. Eventually, they become static in size and may then spontaneously
heal. Some patients have multiple lesions and may succumb to the disorder.
Lesions may recur or new ones may develop after a quiescent phase.
Aetiopathogenesis
The disorder may occur in the course of ulcerative colitis, Crohns disease,
rheumatoid arthritis or myeloma, although in about half the cases no predisposing cause is found. It has been suggested that the tissue destruction is caused by a
vasculitis, although it is difcult to nd evidence of this.
Figure 11.10 Multiple ulcers of the leg

in pyoderma gangrenosum, which
developed over a 3-day period.
180
Treatment
Drugs, including cyclosporin, minocycline and dapsone, have been reported as

promoting the healing of pyoderma gangrenosum lesions.
VASCULITIC ULCERS
Ulcers may develop in the course of a disorder in which small blood vessels become
inamed and thrombosed (vasculitic). Rheumatoid vasculitis is one such condition in which ulceration may occur. Ulcers often occur on the legs (Fig. 11.11), but
may develop anywhere. They may start from a patch of purpura. Treatment is
directed towards the underlying illness.
HAEMATOLOGICAL CAUSES
Figure 11.11 Vasculitic

ulcer.
Leg ulcers are more common in patients with sickle cell disease and idiopathic
thrombocytopenic purpura.
INFECTIVE CAUSES
Tuberculosis, tertiary syphilis and deep fungus infections can all result in persistent ulcers.
ARTERIOVENOUS MALFORMATION
Shunting of the blood at deeper levels may deprive the overlying skin and cause
ulcers (Fig. 11.12).
Figure 11.12 Ulcerated

area in a vascular
birthmark.
181
MALIGNANT DISEASE
This is an uncommon, but important to recognize, cause of persistent ulceration.
The lesions are usually squamous cell carcinoma or basal cell carcinoma. They
have raised edges and are slowly but relentlessly progressive.

Before treatment is planned, it is important to reach a denitive diagnosis and assess
the social background of the patient. The history and the appearance of the lesion
and surrounding skin are the most important sources of diagnostic information.
A biopsy from the margin may provide useful information and will do no
harm. Bacterial swabs are not often helpful unless the ulcer is obviously clinically
infected, as an open wound will always harbour a large number of microbes.
Haematological tests will identify underlying anaemia, a leucocytosis due to infection and rare haematological disorders.
Venography, arteriography, measurement of blood pressure at the ankle and
ultrasound Doppler blood ow studies are amongst the tests that may assist in
assessment. Laser Doppler devices can even image capillary blood ow in the skin,
providing potentially important information.
Summary
Non-healing may be due to inadequate nutrition,
infection or a congenital disorder (e.g. factor XIII
deciency). Leg ulcers are a very common cause of
disability. The commonest cause of leg ulcers is
venous hypertension due to faulty venous valves,
which is most often seen in the elderly. The
inadequate venous return causes venous
hypertension, resulting in oedema, extravasation of
blood into the tissues, thickening of the small
vessels, perivascular deposition of brin and
inammation leading to brosis.
Oedema, telangiectasia and brown discoloration
usually precede ulceration. Such ulcers are sloughy
and of varying size. They occur around the medial
malleolus and tend to persist, but elevation,
compression bandaging and weight reduction are
important in their treatment. Dressings should be
non-adherent, absorptive and non-toxic.
Ischaemic ulceration is due to inadequate blood
supply to the skin and usually the result of
atherosclerosis. Often, there is an element of
ischaemia in venous ulceration. Affected skin tends

to be pale, smooth and hairless and the ulcer
itself is painful and may occur anywhere over the
foot. Treatment must be directed towards increasing
the blood supply.
Decubitus ulceration is due to localized ischaemia
resulting from pressure on the skin at certain
points, such as over the sacrum and on the heels,
in unconscious or paralysed patients. It can be
prevented by careful nursing.
Neuropathic ulcers are due to repeated trauma to
anaesthetic skin in patients with diabetes or
leprosy. They are often deeply penetrating and often
occur on the soles of the feet.
Pyoderma gangrenosum may occur anywhere over
the skin in patients with ulcerative colitis,
rheumatoid arthritis or no identiable underlying
problem. The ulcers occur on inamed skin and may
enlarge rapidly.
Vasculitis, sickle cell disease and malignant
disease are other causes of ulceration.
182
C H A P T E R
12
Benign tumours, moles,

birthmarks and cysts
Introduction
183
184
186
188
188
192
194
197
Leiomyoma
198
Neural tumours
199
Lipoma
200
200
201
Cysts
202
Treatment of benign tumours, moles and birthmarks
204
Summary
205
Introduction
The many cell and tissue types in skin is responsible for the enormous number of
benign tumours that may arise from it. Despite the large number of such lesions,
they have a limited number of clinical appearances and, because of this, accurate
clinical diagnosis is difcult. The treatment of all the lesions included is discussed
together at the end of the chapter.
183
Benign tumours, moles, birthmarks and cysts

SEBORRHOEIC WARTS
Also known as basal cell papillomas, seborrhoeic warts are extremely common,
benign tumours of ageing skin. Most patients over the age of 40 years have seborrhoeic warts some have literally hundreds. They seem to be most common in
Caucasians, but similar lesions are seen in black-skinned and Asian peoples.
Clinical appearance
Their commonest clinical appearance is that of a brownish, warty nodule or

plaque on the upper trunk (Fig. 12.1) or head and neck regions. Their pigmentation varies from light fawn to black. They may occur as solitary lesions, but are
usually multiple and quite often present in vast numbers (Fig. 12.2). They often
have a greasy and stuck on look. In black-skinned people, they may appear as
multiple, blackish, dome-shaped warty papules over the face, a condition known
as dermatosis papulosa nigra. The differential diagnosis of warty lesions is given
in Table 12.1. When deeply pigmented, they are sometimes mistaken for malignant melanoma.
Figure 12.1 Typical brown/black,

stuck-on warty lesions known as
seborrhoeic warts.
Figure 12.2 Large numbers of

seborrhoeic warts.
184
Table 12.1 Differential diagnosis of warty tumours

Lesion
Comment
Seborrhoeic wart
Mostly in elderly individuals and multiple; may have a

greasy, stuck-on appearance
Viral wart
Not usually pigmented; mostly in younger individuals

on hands, feet, face and genitalia
Solar keratosis
Flat, pink and scaly usually, but can have a horny or

warty surface; mostly on the backs of hands and face
Epidermal naevus
Usually since birth; anywhere on body; often a linear

arrangement

a at seborrhoeic wart
showing church spire
arrangement.
They usually cause no symptoms, but patients complain that they catch in
clothing and are unsightly. They may also irritate and, less frequently, become
inamed and cause soreness and pain.
Histologically, there is epidermal thickening, the predominant cell being rather
like the normal basal epidermal cell. Surmounting the thickened epidermis there is
a warty hyperkeratosis whose arrangement has been likened to a series of church
spires (Fig. 12.3). Within the lesion are foci of keratinization and horn cysts.
EPIDERMAL NAEVUS
Epidermal naevus is the name given to a wide variety of uncommon, localized
malformations of the epidermis. Congenital in origin, they are classied as hamartomata and are usually present at birth.
Clinical appearance
Many epidermal naevi are arranged linearly and are warty. Sometimes they track
along a limb and adjoining trunk and are extensive and disguring. This type is
known as naevus unius lateris (Fig. 12.4). Histologically, there is regular epidermal thickening and hyperkeratosis, often in a church-spire pattern.
Figure 12.4 Naevus unius

lateris linear warty lesion.
185
Figure 12.5 Beckers naevus on the chest wall. The

affected area is pigmented, thickened and hairy.
Figure 12.6 Typical orange plaque of naevus

sebaceous on the scalp.
VARIANTS
Beckers naevus is an odd type of hamartomatous lesion that develops in adolescence or early adult life. It usually occurs around the shoulders or upper arms, but
is not unknown elsewhere. A comparatively large area of skin is affected by a
brownish and sometimes hairy plaque (Fig. 12.5). It consists of hypertrophy of all
the epidermal structures, including the hair follicles and melanocytes.
Naevus sebaceous lesions are yellowish orange plaques on the scalp, which contain
hypertrophied and deformed structures of epidermal origin in various amounts.
They are either present at birth or shortly afterwards, and may enlarge, thicken and
develop other lesions in them, such as basal cell carcinoma in adult life (Fig. 12.6).

The more common benign tumours of sweat gland origin are listed in Table 12.2.
The most common are described below.
SYRINGOMA
Syringoma lesions are multiple, small, white or skin-coloured papules that occur
below the eyes (Fig. 12.7) in young adults. Uncommonly, they are also evident on
the arms and lower trunk. Histologically, there are tiny, comma-shaped epithelial
structures, some of which appear cuticle lined, forming microcysts (Fig. 12.8).
CYLINDROMA
This is a benign tumour arising from apocrine sweat glands that, like syringoma,
is often multiple. Smooth, pink and skin-coloured nodules and papules occur over
186
Table 12.2 Benign tumours of sweat gland origin

Syringoma
Multiple white papules beneath eyes; composed of

tiny cysts and comma-shaped epithelial clumps
Cylindroma
Solitary or multiple nodules on face or scalp; clumps

of basaloid cells with eosinophilic colloid material
Syringocystadenoma
papilliferum
Mostly develop in naevus sebaceous on scalp

or on mons pubis
Nodular hidradenoma
Skin coloured or, rarely, pigmented solitary nodule of

epithelial cells and ducts
Eccrine poroma
Solitary nodule on palms or soles or, rarely, elsewhere;

basaloid clumps in upper dermis
Eccrine spiradenoma
Tender and painful solitary nodule
Figure 12.7 Syringoma lesions beneath the eye.
Figure 12.8 Pathology of syringoma showing many

comma-shaped epithelial structures and tiny cysts.
the scalp and face in young adults. Oval and rounded masses of basaloid epidermal cells surrounded by an eosinophilic band of homogeneous connective tissue
characterize the histological appearance.
NODULAR HIDRADENOMA
This is a rare benign tumour of sweat gland epithelium. It is usually solitary and
may be pigmented. Histologically, it consists of clumps of small epithelial cells
amongst which are duct-like structures.
ECCRINE POROMA
Eccrine poroma describes an eccrine sweat duct-derived tumour that arises predominantly on the palms and soles in adults. Histologically, the lesion appears
187
contiguous with the surface epidermis and consists of basaloid cells in which there
are cuticularly lined duct-like structures.

PILOMATRIXOMA
Pilomatrixoma (calcifying epithelioma of Malherbe) develops around the head,
neck and upper trunk in young adults as a solitary, smooth, skin-coloured or
bluish nodule. Clumps of basal cells progressively become calcied and eventually
ossied, leaving behind their cell walls only (ghost cells).
TRICHOEPITHELIOMA
Trichoepithelioma is more often multiple than solitary and usually occurs over
the scalp and face. Histologically, it consists for the most part of clumps of epithelial
cells and horn-lled cysts.
SEBACEOUS GLAND HYPERPLASIA

Sebaceous gland hyperplasia is a common feature of elderly skin and has been suspected to be due to chronic solar damage rather than ageing. One or, more often,
several yellowish, skin-coloured papules develop over the skin of the face, some
of which have central puncta (Fig. 12.9). They are often mistaken for basal cell
carcinomata or dermal cellular naevi. Histologically, they consist of hypertrophied
lobules of normal sebaceous gland tissue.
CLEAR CELL ACANTHOMA (DEGOS ACANTHOMA)

Clinically, this is usually a moist, pink papule or nodule on the upper arms, thighs
or trunk that has been present, unchanging, for several years. The name derives
from the epidermal thickening composed of large cells that, when stained with
periodic acid-Schiff reagent, are found to be stuffed with glycogen (Fig. 12.10)
and inltrated with polymorphonuclear leucocytes.

These are developmental anomalies consisting of immature melanocytes in abnormal numbers and sites within the skin. They are very common and, on average,
white-skinned Caucasians have 16 over the skin surface. Melanocytic naevi come in
a wide variety of shapes and sizes and the main types are summarized in Table 12.3.
188
Figure 12.9 Sebaceous gland hyperplasia. Note the

multiple yellowish papules on the face.
Figure 12.10 Pathology of clear cell acanthoma showing

hypertrophied epidermis with areas of large, pale
epithelial cells.
Table 12.3 Main varieties of melanocytic naevi

Type
Clinical features
Comment
Congenital/simple
Present since birth, tend to be larger than

acquired naevi
Increased tendency for malignant

transformation
Girdle
Cover large areas around pelvic or pectoral

zone (bathing trunk or cape naevus)
Compare to acquired naevi
Acquired
Develop mainly in late childhood and early

adolescence
Junctional
Macular, brown/black
Anywhere on skin or mucosae
Dermal cellular
Papular or nodular, may be hairy; usually

light brown or skin coloured
Very common on face and scalp
Compound
Combination of dermal, cellular and junctional
Naevus spilus
Large, speckled, light-brown naevus
Uncommon
Dysplastic naevus
syndrome
Many moles with irregular margins and

pigmentation; may be sporadic but
also familial
Increased tendency to malignant

melanoma
Juvenile melanoma
Orange-pink nodule or plaque in childhood
Histological picture may simulate

melanoma
Blue naevus
Blue due to depth of pigment in dermis
Cellular blue naevus
Bluish nodule on scalp, hands or feet
Mongolian spot
Large, at, greyish blue macule
Present at birth over sacrum; may fade
Naevus of Ota or Ito
Flat, blue-grey areas on face and neck
Predominantly in Asians
189
Figure 12.11 Large congenital melanocytic naevus.
Figure 12.12 Congenital naevus affecting

most of one hand.
CONGENITAL NAEVI
These lesions, which are present at birth, are usually solitary and dark brown, and
are more than 1 cm2 in size. They are plaque-like or nodular (Fig. 12.11). They
share with the limb girdle naevus the increased tendency to malignant transformation. It has been suggested that 10 per cent of the larger congenital naevi develop
malignant melanoma.
The most deforming congenital melanocytic naevi are those that cover large
tracts of skin on the pelvic region and adjoining back (bathing trunk naevi) or
over the shoulder region and upper limb (cape naevi: Fig. 12.12). Histologically,
these lesions consist of numerous packets (theques) of naevus cells (Fig. 12.13),
which may be small and basophilic (lymphocytoid), large and less intensely staining (epithelioid) or spindle shaped. They may also coalesce to form naevus giant
cells or, after they have been present for many years, may show degenerative
changes, including fatty degeneration and calcication. Naevus cells tend to be
faceted together in a rather characteristic way.
ACQUIRED NAEVI
Acquired naevi appear after birth, usually during adolescence or young adult life.
Potential difculty arises when an adult notices a brown lesion for the rst time.
Has it been there for many years before being noticed? Or is it a new benign mole,
190
(b)
(a)
Figure 12.13 (a) Pathology of congenital melanocytic naevus showing packets or theques of naevus cells, some of
which are naevus giant cells. (b) Many large naevus giant cells.
Table 12.4 Differential diagnosis of an acquired naevus

Diagnosis
Comments
Acquired naevus (male)

Seborrhoeic wart (keratosis, basal cell papilloma)
Dermatobroma (histiocytoma)
Malignant melanoma
Pigmented basal cell carcinoma
Usually light brown, static

Brown, warty
Firm, light brown
Enlarging, irregular, variegate
Smooth, pigmented nodule
some other pigmented lesion, or a malignant melanoma? The differential diagnosis for this situation is given in Table 12.4.
JUNCTIONAL NAEVI
These are at, brown or black moles in which clumps of naevus cells can be
observed at the dermoepidermal junction (Fig. 12.14) nestling in dermal papillae.
It is presumed that this is the rst stage in the life cycle of the ordinary mole.
DERMAL CELLULAR NAEVI

Clumps of naevus cells are found within the upper dermis, accounting for the
papular or nodular nature of these lesions. They are fawn or light brown or just
skin coloured. They are common on the face and are often hairy, accounting
for occasional episodes of pain, redness and swelling due to folliculitis. In some,
there is a deep component with many spindle-shaped naevus cells that may supercially resemble the cellular component of a neurobroma (see page 199). In the
191
Figure 12.14 Many groups of naevus cells at the

dermoepidermal junction in junctional naevus.
Figure 12.15 Blue naevus.
elderly when there is little pigment, they are often misdiagnosed as basal cell
carcinomata.
COMPOUND NAEVI
These have the characteristics of a dermal cellular naevus, but there are areas of
junctional activity with foci of naevus cells at the dermoepidermal junction. It is
presumed that these lesions are intermediary in development between the junctional naevus and the dermal cellular naevus.

Naevus cell naevi gradually become fewer during the ageing process and it is
believed that moles develop involutional changes before disappearing. Some develop
lipid vacuoles in their substance, others develop a type of foamy change, and others
appear to calcify before nally disappearing.
BLUE NAEVI
In the ordinary cellular blue naevus, the melanin pigment and the bulk of the
naevus cells are in the mid and deep dermis. The striking blue colour given by the
pigment is due to the red wavelengths being ltered out by the supercial dermis
and epidermis. This type of blue naevus is found over the scalp (Fig. 12.15) and
the back of the hands or feet.
The Mongolian spot is a type of blue naevus commonly found in Asiatics. It
occurs as a greyish discoloration over the sacral area in the newborn, becoming
less prominent in later life.
192
Figure 12.16 Naevus of Ota.
Figure 12.17 Multiple dysplastic

moles with irregularity of shape
and pigmentation.
The naevus of Ota and the naevus of Ito are due to spindle-shaped naevus cells
over the upper face and lower face and neck, respectively (Fig. 12.16).
DYSPLASTIC NAEVUS SYNDROME (i.e. ATYPICAL MOLE

SYNDROME)
Recognition of this syndrome is important because of the increased frequency of
malignant melanoma associated with it. The condition may occur sporadically,
but is also familial in many patients.
The lesions are variable in number and quite large compared to ordinary
moles. They have irregular margins and irregular brown pigmentation, some having an orange-red hue (Fig. 12.17). It is said that the risk of a melanoma developing is approximately 1 per cent, but it is certainly much more than that in the
familial form if one of the affected members of the family has had a melanoma
perhaps 10 per cent. It is even greater possibly 100 per cent if the individual
has already had one melanoma.
These lesions often have what the dermatopathologists call a worrying appearance, meaning that many have one or more features suggesting melanoma. There
may be a degree of cytological atypia and excessive mitoses.
193
JUVENILE MELANOMA
This is a quite uncommon, benign lesion of childhood and adolescence. Although
usually solitary papules or small plaques, the lesions are occasionally multiple
(Fig. 12.18). The individual lesions are pink or orange and may have a corrugated
or peau dorange surface. Their name derives from their histological appearance,
which may look frighteningly like a melanoma to the uninitiated.

STORK MARK
Figure 12.18 Juvenile
melanoma: a red nodule on
the arm of a 9-year-old boy.
This is the popular name for the red discoloration at the back of the neck in a high
proportion of newborns. It fades in later childhood and seems to be due to
vasodilatation rather than to an excess of blood vessels.
PORT-WINE STAINS
These common vascular malformations may occur anywhere, but seem to be
most common on the face and scalp. The deep crimson colour (or port wine) is
distinctive and cosmetically very disguring (Fig. 12.19). The lesions contain
many dilated blood vessels but no other obvious histological abnormality.
The surface of the lesion becomes more thickened and rugose with age and
even develops polypoid outgrowths, adding to the grotesque appearance. When
on a limb, deep vascular malformations may also be present, which can cause limb
hypertrophy. Over the ophthalmic region, the obvious skin malformation of
blood vessels may be associated with an underlying meningeal angiomatous
malformation. When this combination of lesions is associated with epilepsy, the
disorder is known as the SturgeWeber syndrome.
Figure 12.19 Typical

port wine stain.
194
CAPILLARY ANGIOMA
The lesions are usually present at birth, but may develop in the rst few months of
life. They are raised, purplish nodules and plaques whose surface is often lobulated
(supposedly like a strawberry) and show an enormous range of sizes. The smaller
lesions have little functional signicance (Fig. 12.20) and usually atten or disappear at puberty. The larger lesions are very deforming and may cover quite a large
area of skin (Fig. 12.21). The larger lesions, particularly, may ulcerate after minor
trauma, presumably due to ischaemia of the overlying supercial dermis and overlying epidermis because of the shunting of blood between the larger, deeper vessels
of the angioma. Any bleeding can be stopped with gentle pressure and the eroded
area gradually heals with routine care. One other rare complication only occurs with
the largest of capillary angiomas. Blood platelets become sequestered in the abnormal vascular channels of the angioma, creating a consumption coagulopathy and
uncontrolled bleeding (KatzenbachMerritt syndrome). The bleeding can be dealt
with by administration of systemic steroids.
Figure 12.20 Small

strawberry naevus on the
left side of the nose.
CAVERNOUS HAEMANGIOMA
This is a soft, compressible, mauvish-blue swelling composed of large vascular
spaces. This lesion shows little tendency to reduce in size in later life.
LYMPHANGIOMA CIRCUMSCRIPTUM
This lesion is a malformation of lymphatic channels, although there may also be
an associated blood vessel anomaly. The lesions usually have a deep component,
which it is almost impossible to eradicate surgically. Clinically, the malformation
is recognized as a diffuse skin swelling with what appears to be a cluster of tense
vesicles at the skin surface, with a frogspawn-like appearance (Fig. 12.22).
Figure 12.21 Large capillary naevus affecting the thigh

and lower abdomen.
Figure 12.22 Lymphangioma circumscriptum affecting

the abdomen. There is a deep component making
eradication difcult.
195
Figure 12.23 Angiokeratoma of the

scrotum.
ANGIOKERATOMA
There are several types of angiokeratoma, which all consist of a small, subepidermal vascular malformation surmounted by a hyperkeratotic epidermis. They may
occur as solitary red papules or, occasionally, as a crop of red spots over the scrotum (Fig. 12.23). When literally hundreds of tiny red papules develop over the
trunk in young men, the possibility of the very rare inherited metabolic abnormality known as angiokeratoma corporis diffusum must be considered.
SENILE ANGIOMA (CAMPBELL DE MORGAN SPOT, CHERRY

ANGIOMA)
As with seborrhoeic warts and skin tags, senile angioma is a frequent accompaniment of skin ageing. Histologically, it resembles the capillary angioma, but clinically
its smooth-surfaced, dome-shaped, purplish or cherry-red appearance is quite
characteristic (Fig. 12.24). Many lesions may appear over a period of some months,
but apart from the distress that their appearance seems to cause, they have no special signicance for general health.
CAPILLARY ANEURYSM
Figure 12.24 Senile
angioma on the trunk in a
man aged 63 years.
Because the commonest presentation of this tiny vascular lesion is of a suddenly

appearing black pinhead spot, it is sometimes mistaken for an early malignant
melanoma. If left, it gradually fades.
196
GLOMUS CELL TUMOUR

This benign vascular tumour arises from the glomus cells controlling tiny vascular
shunts between arterial and venous capillaries at the periphery. The constituent
cells have a characteristic cuboidal appearance and the lesion, which often occurs
around the ngertips, is often quite painful.
PYOGENIC GRANULOMA
This odd lesion characteristically appears suddenly over a week or two and then
disappears after several weeks. Typically, it is a red, dome-shaped papule with a
glazed or eroded surface (Fig. 12.25), often on the ngers and toes. Histologically,
it consists of a matrix of oedematous, glassy connective tissue in which there
are numerous thin-walled vascular channels and a moderately dense, mixed
cellular inltrate. Its cause is unknown and it is certainly not due to pyogenic
micro-organisms.
Figure 12.25 Domeshaped, plum-red-coloured,

shiny nodule of pyogenic
granuloma.
Dermatobroma (histiocytoma, sclerosing

haemangioma)
There are no true bromas of dermal connective tissue and it is not certain
whether the dermatobroma is a benign neoplasm or some form of localized
chronic inammatory disorder. It certainly does contain many spindle-shaped
and banana-shaped mononuclear cells, which may be broblast derived, and there
is a variable amount of new collagenous dermal connective tissue. There are also
many histiocytic cells present, which often contain lipid or iron pigment, both of
which may derive from the large number of small blood vessels also contained in
the lesion.
Clinically, dermatobromas are rm or hard intracutaneous nodules. They are
usually found on the limbs as solitary lesions, but sometimes two or three or even
more are found in the same patient. Generally they are brownish in colour (from
the haemosiderin pigment) and have a rough or warty surface because these dermal nodules have the propensity to thicken up the epidermis immediately above
them (Fig. 12.26). The lesions have no serious clinical signicance, but are sometimes mistaken for melanomas.
HYPERTROPHIC SCAR
A scar is a reparative response to injury of some kind, accidental or surgical, or tissue destruction from an inammatory skin disorder, in which the tissue architecture cannot be entirely restored and the defect is made good with brous tissue.
Figure 12.26 Dermatobroma: brownish red, rm,

intracutaneous nodules.
197
A hypertrophic scar is usually pink, smooth and variably raised (Fig. 12.27). The
excess scar tissue generally attens after some months or can be encouraged to
do so with topical corticosteroids and rm pressure bandaging.
KELOID SCAR
Figure 12.27 Hypertrophic

scar.
Like hypertrophic scar, this lesion arises in response to injury, but the response is
inappropriate to the often minor degree of trauma. It tends to occur in young
adults and adolescents, particularly women, and particularly around the shoulders, upper limbs and upper trunk. Some ethnic groups also appear more likely to
develop these lesions, black-skinned individuals being particularly prone.
Clinically, the lesions are raised and appear to send extensions into neighbouring
skin (Fig. 12.28). They show little tendency to regress, and surgical treatment
alone is usually insufcient, as they tend to recur in the scar. Corticosteroids,
interferons, radiotherapy and topical retinoic acid have all been tried, with
varying success. The use of silastic sheeting applied rmly to the affected area
has been claimed to be effective. The histological appearance of keloid scar,
with oedematous, pale connective tissue, suggests reversion to embryonic type of
collagen.
Figure 12.28 Keloid

scar occurring at the site
of a scar from a
Caesarean section.
Leiomyoma
This is an uncommon benign tumour of plain muscle that arises either from arrector pilores muscle of hair follicles or from the smooth muscle of blood vessel walls.
It is mostly smooth surfaced, oval and bluish red in colour, varying in size from
1 cm to 3 cm in length and 0.5 cm to 1.5 cm in breadth. It may be spontaneously
painful, especially in the cold, and indeed can sometimes be seen to contract when
cooled. It can be confused histologically because of its spindle-shaped and strapshaped plain muscle cells, which may look like brous or neural tissue.
198
Neural tumours
Neural tumours
These are, in fact, tumours of the connective tissue accompanying the neural
elements.
NEUROFIBROMA AND VON RECKLINGHAUSENS DISEASE

The neurobroma is mostly multiple and part of a, not uncommon, inherited
syndrome known as neurobromatosis or Von Recklinghausens disease.
The individual lesions are often quite large, soft, compressible and skin coloured
(Fig. 12.29). Histologically, the typical picture is of a non-encapsulated dermal
mass composed of interlacing bundles of spindle-shaped cells, often in a nervelike arrangement, set in a homogeneous matrix amidst which mast cells may be
seen. Von Recklinghausens syndrome is inherited as a dominant characteristic,
but 3050 per cent of patients do not give a family history, suggesting that there
is a high rate of new gene mutation.
Neurobromata start to appear in childhood and increase in numbers during
adolescence. They are cosmetically very disabling and in the worst cases result in
gross deformity. Ultimately, large numbers may be present. Some of these lesions
become very large, soft, diffuse swellings; others become pedunculated and pendulous. Alongside the neurobromata, light-brown, uniformly pigmented, irregular macular patches appear (caf au lait patches) over the trunk and limbs
(Fig. 12.30). A useful diagnostic point is the presence of small, pigmented macules
Figure 12.29 Soft mauve

or pink, compressible
lesions of neurobroma.
Figure 12.30 Caf au lait patch in Von Recklinghausens disease.

199
at the apices of the axillae. There is a greatly increased risk of tumours affecting
the central and peripheral nervous systems as well as of tumours of sympathetic
tissue such as phaeochromocytoma. Genetic counselling of affected individuals is
of great importance.
NEURILEMMOMA
The neurilemmoma is an uncommon benign tumour of neural connective
tissue. The lesions vary in size and occur anywhere on the skin surface. Microscopically, they consist of thin, spindle-shaped cells arranged in a stacked or storiform manner.
NEUROMA
This rare, benign neural tumour is the most differentiated of all the neural connective tissue tumours and consists of well-formed nerve elements. It occurs at
the site of nerve injury and occasionally seems to arise spontaneously.
Lipoma
Lipomata are common, solitary or sometimes multiple, benign tumours of fat.
They may be enormous in size or only 12 cm in diameter and can occur anywhere. They are soft, skin-coloured and have poorly dened edges. Histologically,
they consist of mature fat cells.

These are rare intracutaneous plaques and nodules, often with a knobbly or corrugated skin surface. They are very difcult to identify histologically because they
are composed of normal connective tissue. They may occur as shagreen patches
in tuberose sclerosis.
TUBEROUS SCLEROSIS (EPILOIA)

This recessively inherited syndrome is a neurocutaneous disorder. The cutaneous
components include shagreen patches (see above), ash leaf-shaped hypopigmented
patches on the trunk, subungual bromata, which are brous nodules that develop
beneath the toenails and ngernails, and adenoma sebaceum. Adenoma sebaceum
occurs on the cheeks and the central part of the face of patients with tuberose
200
Figure 12.31 Pink nodules

characterizing the disorder known
as adenoma sebaceum.
sclerosis. Pink or red, rm papular lesions develop (Fig. 12.31) in which vascular
brous tissue is found rather than an excess of sebaceous glands.

These lesions are characterized by an excess of mast cells that may or may not
release histamine and occasionally heparin on stimulation.
MAST CELL NAEVUS (MASTOCYTOMA)

This lesion represents one, or occasionally several, localized collections of mast
cells. It presents as a pink or red nodule, 13 cm in diameter in infants and young
children, but usually disappears spontaneously later in childhood. Rubbing or
heating it may result in it swelling and a red halo Dariers sign.
MASTOCYTOSIS (URTICARIA PIGMENTOSA)

This term is used to describe a group of disorders in which there may be excess
mast cells in many tissues, but which is mainly manifest in the skin. The term
urticaria pigmentosa was formerly employed because it is not uncommon for the
201
Figure 12.32 Red-brown papules of

urticaria pigmentosa.
individual lesions to become pigmented. In the juvenile form, numerous pink or

red-brown papules develop over the trunk and limbs (Fig. 12.32). In some young
patients, the lesions are intensely itchy and they experience discomfort and erythema when bathing. Juvenile mastocytosis usually remits spontaneously during
adolescence.
In the adult, the papular variety is somewhat like the juvenile form except that
it persists. Another adult type is telangiectasia macularis eruptiva perstans of
Parkes Weber. Clincially, in early adult life, pink or pink-brown telangiectatic
macules start to appear, persist and increase in number over the years.
In all the generalized varieties of mastocytosis, studies have shown that there
are deposits of mast cells in visceral structures such as liver, spleen and bone in an
appreciable number of cases up to 20 per cent in some series. They are mainly
of importance if alcohol, opioids or other drugs cause histamine release. Special
xation (e.g. in alcohol) and special stains (e.g. toluidine blue) are necessary to
show up the metachromatic granules of the mast cells.
Cysts
A cyst is an epithelium-lined cavity lled with uid or semi-solid material. The
distinguishing features of the commonly encountered cysts of the skin are summarized in Table 12.5.
202
Cysts
Table 12.5 Differential diagnosis of common skin cysts

Cyst type
Body site
Clinical features
Epidermoid
Virtually anywhere
Smooth-walled, rm lesions may become

inamed if they leak; common
Milium
At sites of blistering, spontaneously

on upper cheeks
Pinhead-sized, white, hard lesions
Pilar
Scalp and scrotum
May be inherited; often multiple; less common

than epidermoid cysts; smooth walled but not as
rm as epidermoid cysts
Sebocystoma
multiplex
Anywhere, but especially the upper trunk
May be inherited; always multiple; usually

small, smooth walled; contents less rm than
other types; may become inamed and develop
acne-like lesions; uncommon
Dermoid
Face, particularly around the eyes
Deep set in skin; may be oval and less mobile

than other cyst types
EPIDERMOID CYSTS
These lesions are lined by epidermis and produce stratum corneum. They are
often surrounded by a tough, brous capsule, presumably stimulated by leakage
of the cyst contents. If these cyst contents nd their way into the dermis, considerable inammation results. The horny content may eventually degenerate,
forming a foul-smelling, semi-solid material. The fancied resemblance of this
to sebum has mistakenly led to the term sebaceous cysts for these lesions.
Epidermoid cysts may occur anywhere, but are most common over the head, neck
and upper trunk.
MILIA
Milia are tiny epidermoid cysts that occur at the sites of subepidermal blistering
as in porphyria cutanea tarda (see page 259) or spontaneously over the upper
cheeks and beneath the eyes. They are usually no larger than a pinhead and are
white. They contain tiny accretions of horn, which can be expressed by slitting the
thin epidermis over them with a needle tip.
PILAR CYSTS (TRICHOLEMMAL CYSTS)

The lining epithelium of these less common cysts is derived from a portion of the
hair follicle neck and shows a quite characteristic type of keratinization in which
there is abrupt formation of a glassy-appearing type of horn without a granular cell
203
layer. Pilar cysts are usually multiple and are often genetically determined as an autosomal dominant trait. They occur on the scalp and on the scrotum in particular.
SEBOCYSTOMA MULTIPLEX (STEATOCYSTOMA MULTIPLEX)

These cystic malformations are formed from sebaceous gland tissue and other
hair follicle-derived epithelium. They are always multiple, often being present in
very large numbers. They are inherited as an autosomal dominant trait. Their
content is sometimes pure sebum. Large numbers of small cysts are distributed
over the body, but particularly over the upper trunk.
DERMOID CYSTS
Dermoid cysts are uncommon lesions that seem to contain embryonic epithelium
capable of forming a wide spectrum of tissue types. They may occur anywhere, but
are especially often found around the eyes as oval, rm, smooth-walled swellings.
FOLLICULAR RETENTION CYSTS

When large hair follicles develop a hard, immovable comedonal plug in the follicular neck or at the skin surface, the follicle distends because of the continuing secretion of sebum and production of horny material. Often, these cysts rupture,
causing inammation, but sometimes this does not happen and quite large
swellings are produced. This seems to occur particularly frequently over the back
in the elderly, when they are sometimes known as giant comedones.
Treatment of benign tumours, moles and

birthmarks
It should be remembered that on many occasions it is the appearance of the lesion
that is the predominant concern of the patient and it is not helpful, for example,
to substitute a simple facial mole with an ugly surgical scar. One overriding principle is important to remember: if any form of surgical removal or destruction is
planned, histological evidence of the nature of the lesion is required. Even the
most experienced dermatologist is not more than 6570 per cent accurate in the
clinical diagnosis of non-typical pigmented lesions, and is only a little better with
non-pigmented tumours.
Minimally scarring procedures such as curettage and cautery and shaving of
small, benign, dome-shaped lesions ush with the skin may be adequate and
prevent unpleasant scar formation. Cryotherapy may also be useful for some
supercial lesions. Treatment by lasers requires specialized instrumentation and
personnel with experience and skill.
204
Summary
Case 11
Mrs J.G. was quite confused. Here she was, at the age of 57, developing more
moles on her back and abdomen! She already had ordinary acquired naevi on her
face and arms, as well as a large, pigmented patch of 2 cm2 diameter over her
upper back that she had been born with and that had been termed a congenital
mole. The new brown, warty spots over her abdomen and back irritated and
worried her and she didnt like the look of them. Her doctor told her that these
new pigmented lesions were nothing to worry about, but were common
seborrhoeic warts that could easily be removed by scraping them off curettage
under a local anaesthetic.
Summary
Seborrhoeic warts are extremely common, benign
epidermal tumours of ageing skin. They are usually
brownish and warty and may occur in large numbers
over the trunk. The differential diagnosis includes
epidermal naevus, solar keratosis, viral wart and,
most important of all, malignant melanoma.
Epidermal naevus is a localized, warty nodule or a
at, brownish patch over the shoulder or buttock
(Beckers naevus). Naevus sebaceous is another
type of epidermal naevus, which contains
sebaceous glands and maybe other adnexal
structures.
Benign tumours of sweat gland origin include
syringoma, cylindroma, nodular hidradenoma and
eccrine poroma.
Calcifying epithelioma of Malherbe (pilomatrixoma)
is a common, benign, hair follicle-derived tumour
occurring over the head and neck in young adults,
which eventually calcies.
Sebaceous gland hyperplasia is often seen in
elderly facial skin as one or several yellowish
nodules.
Melanocytic naevi (moles) are extremely common
developmental anomalies that contain many
immature melanocytes. Congenital naevi are
present at birth. They are usually more than 1 cm2
in diameter and dark brown in colour. Some, such
as those that cover large areas of the shoulder or
elsewhere on the trunk, are very deforming. A few of
these develop malignant melanoma.
Acquired naevi appear after birth and include

junctional naevi, which are at, brown lesions
containing clumps of naevus cells at the
dermoepidermal junction, dermal cellular naevi, with
clumps of naevus cells in the dermis, and
compound naevi, with clumps of naevus cells both
within the dermis and at the junction.
In blue naevi, the characteristic colour is due to the
depth of the naevus cells in the dermis. In the
dysplastic naevus syndrome, the naevi are irregular
and odd looking and there is an increased risk of
malignant melanoma. Juvenile melanoma occurs in
children and adolescents and is so called because
of the histological appearance, which can simulate
malignant melanoma.
Port-wine stains are crimson blotches in which there
is marked capillary dilatation compared to a
capillary angioma, which is a red nodule or plaque
containing proliferating endothelial cells. The latter
tend to atten and disappear at puberty. Larger
ones may cause problems from bleeding and/or
erosion. Cavernous haemangiomata are larger and
compressible, containing large vascular spaces.
Lymphangioma circumscriptum contains dilated
lymphatic channels. Senile angiomas (Campbell de
Morgan spot) are bright-red papules on the trunk of
the elderly, with a similar histological appearance to
capillary angiomas. Glomus cell tumours develop
from arteriovenous shunts at the ngertips and
tend to be painful. Pyogenic granuloma suddenly
arises as a moist, red papule and spontaneously
205
subsides after a few weeks. It contains primitive

connective tissue, inammatory cells and
thin-walled blood vessels.
Dermatobroma (histiocytoma) is a brownish, rm,
intracutaneous nodule containing broblasts,
histiocytes and vascular channels, which may be
inammatory in origin. Several may develop
simultaneously on the limbs. Keloid scars are
unsightly scars, larger than the original injury,
containing embryonic connective tissue and difcult
to eradicate.
Neurobroma is a benign tumour of neural sheath,
which is mostly seen as part of a dominantly
inherited disorder (Von Recklinghausens disease)
in which multiple lesions occur alongside at, brown
macules (caf au lait patches). Whorls of spindle
cells are typical in this lesion. Neurilemmoma is
another benign tumour of neural sheath.
Connective tissue naevi are uncommon, but are of

importance in the inherited disorder known as
tuberose sclerosis, in which brovascular lesions
occur on the face (adenoma sebaceum) alongside
connective tissue naevi on the trunk
(shagreen patches).
Mastocytosis (urticaria pigmentosa) causes
pigmented lesions in the skin which may urticate.
Mast cells may also proliferate in other organs such
as the marrow and the liver.
Cysts are epithelial-lined cavities. Common
epidermoid cysts have a lining epidermis that
produces horn. Pilar cysts lined with hair-sheath
epithelium produce a different type of horn. Cysts
also develop from sebaceous gland tissue known
as sebocystoma multiplex. Dermoid cysts are
congenital in origin and contain a mixture of
tissues.
206
C H A P T E R
13
Malignant disease
of the skin
Introduction
207
207
219
224
Summary
226
Introduction
All forms of malignant disease of the skin are becoming more common. The reasons for this are:
increased exposure to solar ultraviolet radiation (UVR)

an increasingly elderly population
increasing exposure to an increasing number of carcinogenic substances
an increasing number of people who are immunosuppressed.

SOLAR KERATOSES (ACTINIC KERATOSES)
Denition
Solar keratoses are common, localized areas of epidermis due to chronic

solar exposure in which epidermal growth and differentiation are irregular and
abnormal.
Clinical features
The typical solar keratosis is a raised, pink or grey, scaling or warty hyperkeratotic
plaque or papule (Fig. 13.1). Solar keratoses are usually 25 mm in diameter,
Figure 13.1 Typical solar

keratosis.
207
Malignant disease of the skin
Figure 13.2 Large solar keratosis

affecting the left cheek.
Table 13.1 Differential diagnosis of scaling and/or warty lesions on exposed sites
Diagnosis
Comments
Solar keratosis
Small, may be pink
Bowens disease (intraepidermal

epithelioma)
Often large, may be psoriasiform
Squamous cell carcinoma
History of recent growth, may ulcerate
Viral wart
Mostly in young, usually small
Seborrhoeic wart (keratosis, basal cell

papilloma)
May be multiple, often brown
Epidermal naevus
Often linear, present from early age
but may be much larger (Fig. 13.2). They are found on the exposed areas of skin
of elderly, fair-skinned subjects who show other signs of solar damage. Multiple lesions are the rule, and when a solitary solar keratosis is found, it may be
assumed that there is widespread solar damage and that further solar keratoses
will appear.
The differential diagnosis of small scaling or warty lesions of exposed skin sites
is given in Table 13.1. The clinical diagnosis of solar keratosis may be difcult and
with not quite typical lesions, an accuracy of more than 65 per cent is good, even
for experienced clinicians.
208
PATHOLOGY: AETIOPATHOGENESIS OF BOTH SOLAR

KERATOSES AND NON-MELANOMA SKIN CANCER
Parakeratosis and/or hyperkeratosis surmount the variably thickened epidermis,
which demonstrates heterogeneity of cell and nuclear size, shape and staining
(epidermal dysplasia). The edges of the epidermal abnormality are usually quite
distinct and sloped. Sweat ducts are conspicuously uninvolved. There is always a
subepidermal inammatory cell inltrate of lymphocytes, which is occasionally a
dense lichenoid band.
Chronic exposure to solar UVR is the most important causative agency,
although chronic heat damage, X-irradiation and chemical carcinogens (such as
arsenic) may also be responsible in some subjects. The fact that solar keratoses
occur alongside other forms of solar damage on light-exposed skin in fair-skinned
subjects who have had much sun exposure, and similar lesions can be produced
experimentally by UVR in mice, is persuasive evidence that solar UVR is of major
importance.
It is thought that solar keratoses represent one pre-malignant phase on the
path to squamous cell carcinoma, even though only a tiny proportion (perhaps
0.2 per cent) ever transform to malignant lesions.
The role of papillomaviruses in the causation of skin cancer has long been
debated. Modern techniques (e.g. in situ hybridization) indicate that some antigenic types of human papillomavirus (HPV), e.g. HPV16 and HPV18, may provoke neoplasia. The high prevalence of non-melanoma skin cancer (NMSC) in
renal transplant patients is believed to be due, at least in part, to papillomaviruses.
Immunological factors are also of importance in the development of solar keratoses and other forms of NMSC. As mentioned above, patients who have had
renal transplants and who are immunosuppressed have a greatly increased incidence of solar keratosis and NMSC, depending on the length of time they have
been immunosuppressed. Patients with acquired immune deciency syndrome
(AIDS) are also at increased risk of skin cancer (see page 97).
EPIDEMIOLOGY AND NATURAL HISTORY

In the subtropical parts of Australia, solar keratoses have been found in more than
50 per cent of the population over the age of 40 years. In the equable damp climate of South Wales, approximately 20 per cent of the population aged over 60
have been found to have these lesions. Solar keratoses gradually become more
common after the age of 50 years. They are much more common in fair-skinned
subjects, particularly those with reddish hair and blue eyes. Subjects with Celtic
ancestry seem peculiarly sensitive to NMSC from solar exposure and, although
their susceptibility is mostly due to their light complexions, it may be that they
also have some metabolic abnormality akin to xeroderma pigmentosum (see page
218). No racial types are immune to solar keratoses or other forms of NMSC. For
example, albino black-skinned Africans are prone to develop such lesions, and
209
dark-skinned subjects from the Middle East develop NMSC if they are excessively
exposed to the sun.
A small proportion of solar keratoses disappear spontaneously.
TREATMENT
Clearly, solitary lesions or small numbers of solar keratoses may be curetted off or
removed by cryotherapy with liquid nitrogen.
Chemotherapy is sometimes appropriate when there are very large numbers of
lesions present, for individuals who are seriously photodamaged, and three types
are available. The rst is topical 5-uorouracil as a 5 per cent ointment (Efudix,
Roche). This agent is applied daily or twice daily to the lesions over a 10-day or
14-day schedule. The lesions often become sore and inamed, and the patient
should be warned and given a topical corticosteroid to improve the symptoms.
This treatment is effective in some 50 or 60 per cent of cases and often saves considerable inconvenience and discomfort for elderly patients. Topical diclofenac
(Solaraze Shire) also appears to be quite effective. Imiquimod the immune
response-modifying agent may also be used for topical treatment.
Systemic retinoids (either acitretin or isotretinoin) may be used for patients
with multiple solar keratoses or other types of NMSC of several sites for whom
other types of therapy are unsuitable and who can tolerate the uncomfortable side
effects (see page 140). They are given in the same doses as for disorders of keratinisation, for periods of between 3 and 6 months. They reduce the size and number of lesions and reduce the rate of appearance of new lesions. Topical retinoids
are also employed and certainly have a prophylactic as well as a therapeutic effect
when used over long periods.
Intralesional injections of alpha-2B interferon, two or three times weekly
(1 000 000 units of alpha-2B on each occasion), for 3 or 4 weeks causes resolution
in 70100 per cent of lesions of solar keratoses or other types of NMSC. This
treatment is only suitable for very large lesions for which surgical or other destructive types of therapy are unsuitable.
BOWENS DISEASE (INTRAEPIDERMAL EPITHELIOMA)

Denition
Bowens disease is a localized area of epidermal neoplasia remaining within the

connes of the epidermis.
Clinical features
The most typical type of lesion of Bowens disease is a raised, red, scaling plaque,
and lesions are often very psoriasiform in appearance. They are mostly present on
light-exposed areas of skin and are often seen on the lower legs of women (Fig.
13.3), which receive both incident UVR and UVR reected from the pavement.
210
(b)
(a)
(c)
Figure 13.3 (a) Psoriasiform patch of Bowens disease on the lower leg of an elderly
woman. (b) Bowens disease on the cheek. (c) Pathology of Bowens disease showing
irregular thickening of the epidermis and cellular irregularity.
Single lesions are most common, but multiple lesions may occur. Lesions on the
trunk were common when arsenic was used as a treatment for psoriasis and other
chronic ailments. Individual lesions gradually enlarge and thicken and may eventually transform to squamous cell carcinoma.
Pathology and aetiopathogenesis
The histological appearance could be described as an exaggerated version of a

solar keratosis in which there is marked thickening and marked heterogeneity of
the epidermal cells (Fig. 13.3c). Bizarre, large keratinocytes (cellules monstreuses)
complete the distinctive appearance. There is also parakeratosis and a supercial
resemblance to psoriasis.
Erythroplasia of Queyrat
This is the term used for Bowens disease affecting the glans penis. It presents as a
red, velvety patch that slowly progresses, eventually transforming into a squamous
cell carcinoma if left untreated. Surgical excision of the affected area is the best
form of treatment.
SQUAMOUS CELL CARCINOMA/SQUAMOUS CELL EPITHELIOMA

Clinical features
The majority of lesions of squamous cell carcinoma are warty nodules or plaques
that gradually or, in some cases, rapidly enlarge to form exophytic eroded nodules or
211
Figure 13.4 Irregular nodular plaque on

the ear due to squamous cell carcinoma.
Figure 13.5 Eroded nodule of

squamous cell carcinoma.
ulcerated plaques (Figs 13.4 and 13.5). The lesion is in most case solitary, although it
often occurs against a background of solar damage with multiple solar keratoses.
Metastases occur if the primary lesions are left untreated, spreading to local
lymph nodes, local skin sites and ultimately lungs, bone and brain.
The development of squamous cell carcinoma should be suspected in areas of:
severe photodamage
X-ray dermatitis
chronic heat injury such as erythema ab igne
chronic inammatory skin disease such as chronic discoid lupus erythematosus and chronic hypertrophic lichen planus.
There is marked epidermal thickening with cellular and nuclear heterogeneity and
atypia and evidence of abnormal mitotic activity. There is also evidence of focal and
inappropriate keratinization so that so-called horn pearls are formed (Fig. 13.6).
There is usually evidence of invasion of surrounding tissue by epithelial clumps and
columns.
Squamous cell carcinoma has to be distinguished from the massive but benign
epidermal thickening known as pseudoepitheliomatous hyperplasia seen in
hypertrophic lichen planus, prurigo nodularis and lichen simplex chronicus.
The factors in the aetiology of squamous cell carcinoma are as follows.
Chronic UVR damage from solar exposure.

X-irradiation damage to the skin.
212
Figure 13.6 Pathology

of squamous cell
carcinoma showing a
mass of abnormal
epithelium with scattered
areas of differentiation
(horn pearls).
Persistent heat injury to the skin (as in erythema ab igne).

Chronic inammatory and scarring disorders of the skin, such as discoid lupus
erythematosus, hypertrophic lichen planus and dystrophic epidermolysis
bullosa.
Certain genodermatoses and localized congenital malformations, such as xeroderma pigmentosum, epidermodysplasia verruciformis and epidermal naevus.
Papillomavirus infection certain antigenic types (e.g. HPV5, HPV16 and
HPV18) seem particularly likely to cause malignant transformation in immunosuppressed renal transplantation patients, in epidermodysplasia verruciformis
and giant warty tumour of the genitalia.
Exposure to chemical carcinogens, such as industrial contact with tars and
pitch or systemic administration of arsenic.
Epidemiology and natural history
Squamous cell carcinoma predominantly occurs in the same population groups as

described for solar keratosis. Regrettably, it is difcult to obtain accurate gures
for the incidence of the disease, as reporting is not as complete as it should be. In
one survey in subtropical Australia, approximately 2 per cent of the population
over the age of 40 years had one squamous cell carcinoma when examined. Studies
indicate that squamous cell carcinomas as well as other forms of NMSC are increasing in incidence.
Most squamous cell carcinomas are removed before they metastasize, but some
patients die from the spread of their lesion.
Treatment
Excision, with an adequate margin to ensure inclusion of all neoplastic tissue

and some healthy tissue all around the lesion, is sufcient for cure in more than
95 per cent of patients. For the very elderly with solitary, large, difcult to remove
lesions, treatment by radiotherapy may be the kindest and most efcient method.
Systemic retinoids may be appropriate when there are multiple solar keratoses and
213
other signs of photodamage as well as the index lesion, and intralesional interferon may be suitable for large lesions.
KERATOACANTHOMA (MOLLUSCUM SEBACEUM)

This term describes a suddenly appearing epidermal tumour with some of the characteristics of a squamous cell carcinoma, but which resolves after a short period.
It usually appears within a week or two on light-exposed skin as a solitary crateriform nodule (Fig. 13.7). It then gradually enlarges for a few weeks and stays at
that size for a variable period before nally remitting after a total of 3 or 4 months.
Lesions that are more persistent should be suspected of being a squamous cell carcinoma. The most important differential diagnosis is squamous cell carcinoma.
If left to resolve spontaneously, scarring often occurs.
Figure 13.7 Solitary
crateriform nodule
of keratoacanthoma.
Keratoacanthoma has a characteristic, symmetrical, cup-shaped or ask-shaped

structure (Fig. 13.8). There is a minor degree of epidermal dysplasia and little
evidence of tissue invasion. It seems to be provoked by the same stimuli that cause
solar keratoses, but is much less common. It has been suggested that keratoacanthomas develop from hair follicle epithelium.
Treatment
Excision or curettage and cautery may be employed.

of keratoacanthoma.
Note the cup-shaped
epidermal invagination.
BASAL CELL CARCINOMA (BASAL CELL EPITHELIOMA)

Denition
Basal cell carcinoma is a locally invasive but rarely metastasizing malignant

epithelial tumour of basaloid cells without the tendency to differentiate into
horny structures.
214
Table 13.2 Clinical types of basal cell carcinoma

Clinical type
Comment
Nodulocystic
Solid or cystic nodule; commonest
Ulcerative
Usually a later stage of nodulocystic lesion; has a rolled

margin; this type is known as rodent ulcer
Pigmented
Darkly pigmented nodule; may be confused with melanoma
Morphoeic
Flat, white, scar-like; often difcult to diagnose
Supercial
Flat, scaling, pink patch; often with a ne, hair-like margin
Clinical features
There are several clinical types (see Table 13.2).
Nodulocystic. These are by far the commonest variety. Translucent or skincoloured, dome-shaped nodules (0.51.5 cm in diameter) slowly appear on
the skin and remain static for long periods, often for several years, before ulcerating (Fig. 13.9). They often have a telangiectatic overlying skin and may
be ecked with pigment. They usually occur as solitary lesions on the
exposed areas of the skin of the head and neck and are uncommon on the
limbs. Some 20 per cent occur on the trunk. They must be distinguished from
dermal cellular naevi, sebaceous gland hypertrophy and benign hair follicle
tumours.
Ulcerative. The nodulocystic type eventually breaks down to form an ulcer with
raised everted edges (Fig. 13.10). This type is known colloquially as rodent
ulcer.
Pigmented. Nodulocystic lesions may become quite darkly pigmented and are
then quite often mistaken for melanomas (Fig. 13.11).
Figure 13.10 Ulcerated plaque of nodulocystic basal

cell carcinoma (rodent ulcer).
Figure 13.9 Typical nodulocystic basal cell carcinoma.
Figure 13.11 Several small, black nodules of pigmented

basal cell carcinoma on the face of a patient with basal
cell naevus syndrome.
215
Figure 13.12 Eroded sclerotic plaque of morphoeic

basal cell carcinoma.
Figure 13.13 Large supercial basal cell carcinoma

affecting the back. Note the psoriasiform appearance
with the well-dened edge.
Morphoeic. These are often whitish, scar-like, depressed, rm plaques, and are
so named because of their supposed resemblance to localized scleroderma
(Fig. 13.12).
Supercial. These take the form of a variably sized, thin, pink, scaling plaques with
a well-dened edge (Fig. 13.13). If the edge is examined with a hand lens, a ne,
hair-like, raised margin can be discerned. They may be mistaken for Bowens
disease or even a patch of psoriasis. They often occur on the trunk and limbs.
All types of basal cell carcinoma gradually expand and invade and destroy local
tissue structures such as the ear, nose and eye. They metastasize rarely, but it is
difcult to know how often. However, when it is realized that basal cell carcinoma
is one of the most common human tumours and that metastasis has been
recorded in the literature only about 500 times, the proportion of lesions that do
metastasize must be extremely small.
Clumps of small basophilic epidermal cells occupy the upper dermis, the outermost cells often being more columnar than the rest and arranged in a neat palisade
around the nodule (Fig. 13.14). Many mitotic gures may be seen amongst the
mass of basal cells, as may many degenerate cells it is thought that the slow
rate of growth is explained by cell death keeping pace with cell proliferation in
the tumour. In routine histological sections, it is common to nd a gap between the
clumps of tumour cells and the surrounding dermis, due to the dissolving out of
soluble glycoprotein-like material.
Most lesions of basal cell carcinoma are due to chronic solar exposure and
UVR damage, as they occur on light-exposed sites in photodamaged subjects.
However, a larger proportion occurs in younger, non-light-exposed, non-photodamaged subjects than solar keratoses or other forms of NMSC. The explanation
for this is uncertain, but it may be that some lesions arise from congenital malformations and are unrelated to UVR exposure.
216

of basal cell carcinoma
showing well-dened
clumps of basaloid cells
with peripheral palisading.
Epidemiology
The occurrence of basal cell carcinoma mirrors that of solar keratosis. As with
squamous cell carcinoma and other forms of photodamage, basal cell carcinoma
appears to be increasing in incidence.
Treatment
The majority of lesions can easily be excised. Smaller lesions can be curetted and
the base cauterized. Both these surgical ablative techniques result in a 95 per cent
cure. Larger lesions may be treated by radiotherapy after conrming the diagnosis
by biopsy.
Case 12
Liam was a farmer. He had spent most of his 63 years on the land and loved it.
Unfortunately, his skin did not. He had begun to notice lumps, bumps and
scaly patches a few years before, but now they really needed treatment. On his
bald scalp were multiple, scaling patches and small, warty lesions. These were
diagnosed as solar keratoses and were treated by a combination of curettage,
cryotherapy and topical 5-uorouracil ointment. Of more signicance were an
ulcerated, pearly plaque on one nostril and a thick, warty patch on his left ear.
The rst was a basal cell carcinoma and the latter was a squamous cell
carcinoma. Both received expert treatment from the local dermatologist, who was
a dab hand at removing such lesions.
BASAL CELL NAEVUS SYNDROME (GORLINS SYNDROME)

Denition
This is a rare, autosomally inherited condition in which multiple pigmented basal

cell carcinoma lesions develop as part of a multi-system disorder.
217
Clinical features
Multiple basal cell carcinomas may start to develop in the second decade of life
and erupt in large numbers in succeeding years. Less severely affected individuals
start to develop them later in life and develop fewer lesions. The lesions are mostly
pigmented and may occur anywhere on the skin surface. Small pits may be found
on the palms, but otherwise there are no skin abnormalities.
A series of skeletal anomalies is also present in the majority of patients, including mandibular cysts and bid ribs. In addition, patients have a high incidence of
ovarian, central nervous system and spinal tumours.
In recent years, considerable progress has been made in identifying the gene
responsible for this disorder.
Treatment
Individual lesions should be removed as necessary. When there are large numbers
present and new lesions are continuing to appear, the administration of systemic
retinoids will reduce the numbers of lesions and the rate of appearance of new
basal cell carcinomas (see page 140).
XERODERMA PIGMENTOSUM
Denition
Xeroderma pigmentosum is the name given to a group of rare, inherited disorders

in which there is faulty repair of damaged DNA and the development of numerous skin cancers.
Clinical features
The phenotypic expression depends on the particular genetic abnormality responsible, but in all types, pre-neoplastic and neoplastic lesions including solar keratoses, squamous cell carcinomas, basal cell carcinomas and melanomas develop
from childhood, and in the worst cases cause death in later adolescence or early
adult life. The development of skin cancers is accompanied by severe photodamage, resulting in a characteristic and pitiful appearance (Fig. 13.15). In one severe
recessive variety known as the de SanctisCaccione syndrome, there are also crippling neurological defects, including cerebellar ataxia and intellectual impairment.
Epidemiology and natural history
It has been estimated that, overall, the incidence of xeroderma pigmentosum is

1 in 250 000, but in some areas, such as parts of the Middle East, the condition is
unusually common.
Treatment
Management is directed to genetic counselling, removal of neoplastic lesions as

they occur and prevention of further photodamage by advice and sunscreens.
218
Figure 13.15 A patient with xeroderma

pigmentosum. (Reproduced with thanks
to Dr Dafydd Roberts.)
Recently, the use of systemic retinoids has been shown to reduce the rate of development of new cancers and is now an important aspect of the management of
these patients.

LENTIGO MALIGNA (HUTCHINSONS FRECKLE)
Lentigo maligna is a slowly progressive, pre-neoplastic disorder of melanocytes,
which develops insidiously on exposed areas of skin, particularly the skin of the
face. The lesion itself is a pigmented macule with a well-dened, rounded or polycylic edge, which may be up to 5 cm in diameter or even larger (Fig. 13.16). A characteristic feature is the varying shades of brown and black contained within the
lesion a feature known as variegation. The differential diagnosis includes seborrhoeic wart, simple senile lentigo and pigmented solar keratosis (see Table 13.3).
The disorder is usually slowly progressive over a period that may be in excess of
20 years. If left untreated, a true malignant melanoma develops within the lentigo
maligna, which then has the characteristics of a typical malignant melanoma (see
below).
Pathology
There are many abnormal, often spindle-shaped, melanocytic clear cells at the
base of the epidermis and clumps of melanin pigment in the upper part of the
dermis. As the disease progresses, clumps of abnormal melanocytes appear, projecting into the dermis, and a dense inltrate of mononuclear cells develops.
Figure 13.16 Lentigo

maligna. Note the
variegated pigmentation
and irregular margin.
219
Table 13.3 Differential diagnosis of melanoma

Type of lesion
Main differentials
Comment
Lentigo maligna
Seborrhoeic wart, senile

lentigo, pigmented solar
keratosis
Seborrhoeic wart tends to be

warty; senile lentigo is not
variegated; solar keratosis
tends to be scaly and
pink/brown
Supercial spreading
malignant melanoma
Seborrhoeic wart,
pigmented basal cell
carcinoma, vascular
malformation,
melanocytic naevus

warty; basal cell carcinoma
has a pearly look; vascular
lesion may blanch if not
thrombosed; melanocytic
naevus is less variegated
Acral lentiginous
melanoma
Melanocytic naevus,
vascular malformation
Melanocytic naevus is less

variegated; malformation may
blanch if not thrombosed
Malignant melanoma
growing vertically
downwards
Seborrhoeic wart,
pigmented basal cell
carcinoma, vascular
malformation,
melanocytic naevus,
pyogenic granuloma

warty; basal cell carcinoma
has a pearly look; vascular
lesion may blanch if not
thrombosed; melanocytic
naevus is less variegated;
pyogenic granuloma tends to
be redder and smaller than
malignant melanoma
Treatment
This is dictated by the size and exact site of the lesions. Often, they are of size and
site precluding surgical removal. In these instances, other locally destructive measures have been used, including curettage and cautery and radiotherapy. Careful
follow-up is required to detect the earliest signs of development of a frank melanoma.
MALIGNANT MELANOMA
Malignant melanoma is an invasive, neoplastic disorder of melanocytes in which
the tendency is for invasion either horizontally and upwards into the epidermis
(supercial spreading malignant melanoma, SSMM) or vertically downwards
(nodular malignant melanoma, NMM).
Clinical features
Some 50 per cent of lesions of malignant melanoma develop from a pre-existing

melanocytic naevus and the other 50 per cent develop de novo on any part of the
220
Table 13.4 Clinical features of malignant melanoma

Recent
Growth in size, or appearance of new pigmented lesion
Change in colour (mostly increased pigmentation)
Change in shape (development of irregular margin)
Development of itchiness in lesion
Irregularity of margin/pigmentation
Erosion and/or crusting
Appearance of satellite nodules (late)
Enlargement of regional lymph nodes (very late)
skin surface. Any pigmented lesion that suddenly develops or any change in the
size, shape or colour of a pre-existing lesion should be suspected of being a malignant melanoma. Particular signs that are valuable in the recognition of these
lesions are irregularity in the margin or in the degree of pigmentation, and erosion or crusting of the skin surface (Fig. 13.17, Table 13.4). Itchiness of the lesion
is a not uncommon symptom in malignant melanoma.
One way in which this lesion may present is as a rapidly growing, nonpigmented nodule with an eroded surface, looking somewhat like a pyogenic
granuloma (Fig. 13.18).
Another unusual variety of malignant melanoma is the acral lentiginous
melanoma, which develops around the ngers or toes and sometimes subungually. This form has a particularly poor prognosis.
Late local signs are the development of satellite pigmented nodules and enlargement of the regional lymph nodes. Redness and other signs of inammation may
be present, but benign compound moles may also become inamed and inammatory change by itself is not common in malignant melanoma.
Although this is a potentially fatal disorder, the early stages are easily curable
and it is vitally important that every physician learns the signs of malignant
melanoma. Pigmented lesions can be very difcult to diagnose and there is no
shame in requesting another opinion.
The differential diagnosis includes melanocytic naevus (see page 188), pigmented basal cell carcinoma (see page 214), histiocytoma (see page 197) and vascular
malformation (see page 194).
The rate of progress of the disease seems largely determined by the inherent
biology of the malignant melanoma. When the lesion spreads horizontally
(SSMM), it tends to be noted and treated earlier than when the predominant direction of growth is vertically downwards (NMM). It is therefore not surprising that
the overall prognosis is much better for SSMM than for NMM. The single most
important determinant of prognosis appears to be depth of invasion into the
dermis (see below). Thus, patients with small lesions of less than 1 mm invasion
into the dermis have an expectancy of a 5-year survival rate in excess of 95 per cent.
Because of the signicance for prognosis of the depth of invasion into the dermis,
Figure 13.17 Nodular

malignant melanoma. This
lesion enlarged and
darkened over a period of
3 months.
Figure 13.18 Red, shiny

nodule due to malignant
melanoma that was initially
diagnosed as a pyogenic
granuloma.
221
various classications based on microscope measurements have been developed.

The two most common are the Breslows thickness technique and the Clark staging method. In the Breslow technique, three categories are recognized: less than
1.5 mm, 1.53.5 mm, and more than 3.5 mm. Clarks staging method recognizes
ve stages dependent on where the tumour reaches: stage 1 being conned to the
epidermis, and stage 5 where there is inltration of the subcutaneous fat. Stages 2,
3 and 4 describe progressively deeper levels within the dermis.
Spread of malignant melanoma is local, regional and distant. Distant metastases
occur by haematogenous spread. Haematogenous metastases may occur anywhere,
but quite commonly they develop in the lungs, liver and brain. Regional spread is
via the lymphatics to regional lymph nodes. When regional lymph node metastases
have been found, the 5-year survival rate is less than 25 per cent, and when distant
metastases have occurred the comparable gure is around 5 per cent.
Secondary satellite lesions develop around the primary malignant melanoma
in many instances. When metastases are widespread, the production of melanin
pigment and its subsequent release into the circulation may be sufciently great
to result in a generalized darkening of the skin and even excretion of melanin in
the urine (melaninuria), although this is quite rare. Occasionally, regression of
part of the lesion occurs and, rarely, the entire lesion and metastases may undergo
spontaneous resolution.
Overall, men have a worse prognosis than women. Back lesions in men and leg
lesions in women have the least favourable prognoses.
Typically, there are clumps of abnormal melanocytes at the dermoepidermal junction. In SSMM, abnormal melanocytes tend to invade upward into the epidermis
and horizontally along the epidermis. In NMM, there are groups of abnormal cells
invading vertically downwards (Fig. 13.19). There is usually some accompanying
inammatory cell inltrate. It has to be said that the histological diagnosis of
melanoma may be difcult and should be left to the expert.
Solar UVR is believed to be the single most important causative factor, but, as up
to 50 per cent of lesions of malignant melanoma occur on non-sun-exposed sites,
other factors may play a role. The propensity for patients with the dysplastic mole
syndrome (see page 193) and large congenital melanocytic naevi to develop this condition suggests that developmental factors may also be involved in some instances.
There is some evidence that episodes of intense sun exposure over short periods,
with sunburn, may be very harmful. This could explain why malignant melanoma is
relatively common on areas of skin that are only occasionally exposed to the sun.
Epidemiology
Malignant melanoma is rare before puberty, but can occur at any age after that. It
is seen in all racial types, but is more common in fair-skinned, Caucasian types.
Acral lentiginous melanoma seems most frequent in black-skinned individuals
and subjects of Japanese or other Asian descent. The incidence has increased in all
countries that keep accurate gures and increases have been noted since records
222
Figure 13.19 Pathology of malignant melanoma. Note

the irregular clumps of abnormal naevus cells throughout
the upper dermis.
Figure 13.20 Classical Kaposis sarcoma with brown

macules and mauve plaques on the lower legs.
rst began. The rate of increase seems to be of the order of 7 per cent per annum.
The incidence is greatest in Queensland, Australia, and tends to be high in the hot,
sunny areas that have a large fair-skinned population of European descent.
Treatment
The treatment of choice is excision with a generous margin of normal skin. There
is debate concerning the width of the margin, but it should be at least 2 cm around
the lesion for a malignant melanoma of 1 cm diameter. There is also debate as to
whether or not regional lymph nodes should be removed prophylactically. The balance of opinion suggests not, provided that there is no clinical evidence of spread.
Metastatic disease responds poorly, if at all, to chemotherapy, but some decrease
in the size of metastatic deposits and occasional temporary remission have been
noted with combinations of antimetabolites and other anticancer drugs as well as
with retinoids, interferons and interleukin-2.
NEOPLASTIC DISORDERS OF MESENCHYMAL ELEMENTS

Kaposis sarcoma (idiopathic haemorrhagic sarcoma)
Kaposis sarcoma is a rare, multi-focal, malignant vascular tumour of skin and

other organs, which occurs either as an endemic, slowly progressive disease or as
a rapidly progressive disorder in the immunosuppressed.
The endemic type occurs predominantly in elderly males of either Jewish origin from central Europe or of Italian origin from around the Po valley. Mauve or
purplish-red nodules and plaques and brownish macules (Fig. 13.20) develop
223
over the dorsa of the feet and the lower legs. These lesions are usually accompanied by swelling of the lower legs. They are slowly progressive and may not appear
in other sites for many years. It has been estimated that the mean survival time
after the appearance of the rst lesions is approximately 12 years. Eventually,
lesions disseminate to other parts of the skin and to the viscera.
The rapidly progressive type occurs in patients with AIDS, particularly male
homosexuals, renal transplant patients and in areas of Africa notably Uganda.
The clinical manifestations are similar to those of endemic Kaposis sarcoma, but
are much more extensive and much more rapidly progressive.
The lesions consist of abnormal, slit-like vascular channels lined with spindleshaped cells, a mixed inammatory cell inltrate, haemorrhage and brosis. It is
believed that a herpes-type virus is involved in the causation.
Treatment
As the disorder appears to be multi-focal, cure does not appear possible at the
moment. However, radiotherapy keeps localized areas in check and systemic
interferon produces partial regression and remission in many patients. A new
topical retinoid, alretin, has also been shown to be effective.
Dematobromasarcoma
This is a slowly progressive neoplastic disorder of broblasts. It looks quite similar to a histiocytoma histologically and is an intracutaneous form of plaque clinically. Treatment is excision.

MYCOSIS FUNGOIDES
Mycosis fungoides is a multi-focal, neoplastic disorder of T-lymphocytes that primarily affects the skin.
This uncommon disorder starts off as a series of red macules and scaly patches
over the trunk and upper limbs, which gradually extend and become more prolic,
but at rst only cause inconvenience because of their appearance and mild pruritus (Fig. 13.21). The red patches persist, although they may uctuate in intensity,
and eventually start to thicken and become plaques and, later still, eroded tumours
(Fig. 13.22). The ringworm-like appearance of some of the early patches and the
fungating plaques in the late stages were presumably responsible for the term
mycosis fungoides. In the later stages of the disorder, lymph node enlargement,
hepatosplenomegaly and inltration of other viscera occur. At the time of writing,
the disorder is inevitably fatal, although the rate of progress is quite variable, with
survival ranging from 2 or 3 years in some patients to 20 years in others.
224
Figure 13.21 Multiple inltrated, red

plaques on the trunk of a patient with
mycosis fungoides.
Figure 13.22 Eroded nodules on the

palm of a patient with terminal mycosis
fungoides.
The above sequence is the classical type of mycosis fungoides, and other less
common variants are occasionally seen.
SZARY SYNDROME
This is marked by an erythroderma that has a particular intense erythematous
colour, a picture sometimes referred to as lhomme rouge. It is accompanied by
thickening of the tissues of the face, neck and palms. It is also characterized by the
appearance of abnormal mononuclear cells circulating in the peripheral blood.
These cells, which are identied in the buffy coat, are large and have a large,
dense, reniform nucleus.
OTHER FORMS OF T-CELL LYMPHOMA

In addition to the above declared forms of cutaneous T-cell lymphoma, there are
a number of uncommon precursor disorders which were known collectively (and
inappropriately) as parapsoriasis. These by no means always progress to T-cell
lymphoma, and their true nature is uncertain. In addition, they are not well
characterized clinically.
225
Summary
Solar keratoses are localized areas of disorderly
epidermal growth and differentiation due to chronic
solar exposure. Typically, they are small, pink or
grey, warty or scaling lesions on the exposed skin of
fair-skinned, elderly subjects.
Solar UVR, heat, X-rays HPV infection, chronic
arsenic poisoning and immunosuppression are all
factors that may be involved in the causation of
solar keratoses. These lesions may be regarded as
pre-malignant, although they rarely progress and
often spontaneously remit.
Solar keratoses often respond to topical 5-uorouracil,
diclofenac or imiquimod. Systemic retinoids and
intralesional interferons have also been employed.
Bowens disease is a localized area of epidermal
neoplasia remaining within the epidermis, with even
greater cellular irregularity than a solar keratosis.
Red, scaling psoriasiform plaques on the legs are
typical. These plaques enlarge and thicken,
eventually transforming to squamous cell
carcinoma. Erythroplasia of Queyrat is Bowens
disease of the glans penis.
Squamous cell carcinoma is usually a warty nodule
or plaque that eventually ulcerates, invades local
structures, but metastasizes late. Histologically,
there is marked epidermal thickening and
irregularity, with cellular heterogeneity and focal
dyskeratosis. Solar UVR, heat, X-rays, HPV infection,
chemical carcinogens and chronic inammation may
be involved in the aetiology.
Keratoacanthoma arises suddenly as a solitary,
horn-lled crateriform nodule consisting of an
invaginated epidermal cup. It remits spontaneously
after 34 months.
Basal cell carcinoma is a very common, locally
invasive epithelial tumour of basaloid cells.
Nodulocystic types form pearly papules or plaques,
which eventually ulcerate. Some may be pigmented.
Supercial basal cell carcinoma spreads very slowly
as well-dened psoriasiform plaques. Morphoeic
basal cell carcinomas form rm plaques as the
cells evoke a brotic reaction. Histologically, areas
of mucoid degeneration amongst the basophilic
basal cell clumps are common.
Basal cell naevus syndrome is a rare
genodermatosis in which there are multiple
developmental anomalies, multiple pigmented basal

cell carcinomas, bid ribs and palmar pits.
Xeroderma pigmentosum is another rare
genodermatosis in which there is a deciency in the
ability to repair DNA damaged by UVR. This results
in skin cancers of various types.
Lentigo maligna (Hutchinsons freckle) is a slowly
progressive, pre-malignant lesion of melanocytes on
exposed skin. Characteristically, it is a large macule
with varying shades of pigmentation. If left
untreated, a malignant melanoma often develops
within the lesion.
Some 50 per cent of malignant melanomas develop
from a pre-existing melanocytic naevus. The rest
develop de novo. Sudden enlargement, irregularity of
pigmentation and margin, erosion, crusting and
itching are important signs of melanoma. The early
stages are curable and the diagnosis should be
considered in any pigmented lesion. Malignant
melanoma must be distinguished from seborrhoeic
wart, pigmented basal cell carcinoma, pigmented
mole, histiocytoma and vascular malformations.
Lesions of supercial malignant melanoma with
lateral spread have a better prognosis than the
nodular lesions. The depth of invasion into the
dermis is a major prognostic indicator less than
1 mm invasion and there is a better than 95 per
cent 5-year survival. Metastases of malignant
melanoma may occur early. With lymph node
metastases, there is less than 25 per cent 5-year
survival. With blood-borne metastases (liver, lung,
brain), the survival rate is less than 5 per cent.
Kaposis sarcoma is a rare, multi-focal, malignant
vascular tumour of skin, which may occur as a
slowly progressive endemic disease or as a rapidly
progressive disorder in AIDS and other immunosuppressed states. Affected individuals develop
mauve/purple patches, nodules and plaques
in the legs and elsewhere on the skin and in the
viscera.
Mycosis fungoides is a rare, multi-focal, neoplastic
disorder of T-lymphocytes, characterized by the
appearance of red, sometimes psoriasiform,
plaques over the skin, which is ultimately fatal.
Szary syndrome is a similar disorder, but differs in
that the whole of the skin is affected.
226
C H A P T E R
Skin problems in infancy

and old age
Infancy
227
Old age
233
Summary
237
14
Infancy
FUNCTIONAL DIFFERENCES
In the neonatal period and early infancy, the skins defences are not yet fully
developed, and it is much more vulnerable to chemical, physical and microbial
attack. Apart from the depressed skin defences, the surface area to weight ratio is
higher than at other times and there is a greater hazard from increased absorption
of topically applied medicaments. For example, serious systemic toxicity can result
from the application of corticosteroids or a salicylic acid preparation. There is also
a greater rate of transepidermal water loss through intact, non-sweating skin in the
newborn compared to the adult, indicating immaturity of the skins barrier function.
This is easily conrmed by the use of a special water-sensor device known as the
evaporimeter.
During the early weeks of life, newborns possess the blood levels of hormones
found in the mother at birth. This may be of special signicance for the sebaceous
glands, which react to circulating androgenic compounds by enlargement and
increased sebum secretion.
MANAGEMENT PROBLEMS IN INFANCY

Medicaments are absorbed from infants far more easily and are more likely to cause
systemic toxicity. Topical agents that are well tolerated by adults may cause quite
severe reactions in infancy because of the lack of maturity of the barrier.
The ability to scratch does not seem to develop until around the age of 6 months
and, when it does, the rash may alter substantially because of the excoriations and
227
Skin problems in infancy and old age
(b)
Figure 14.1 (a) Atopic dermatitis of the face at age

4 months. There is marked inammation but no
excoriations. (b) Lichenication around the eyes in an
older child due to rubbing.
(a)
the physical effects of persistent scratching on the skin (lichenication) as well as

the presence of infective lesions (Fig. 14.1). The inability of the infant to complain
of discomfort and irritation leads to general irritability and persistent crying.
When this continues for long periods, the parents cannot sleep and the intrafamilial emotional tension spirals upwards within the family home, necessitating
attention to all those involved.
Widespread rashes may lead rapidly to dehydration in infancy because of the
greatly increased rate of water loss through the abnormal skin. The same is true
of heat loss from the inamed skin. Hypothermia can develop very rapidly in
young infants who have a widespread inammatory skin disorder and, like dehydration, is a dangerous complication. These two complications, dehydration and
hypothermia, may be prevented by:
anticipation and monitoring water loss with an evaporimeter and monitoring

body temperature by taking the rectal temperature
nursing infants with severe widespread skin disease in an incubator or supplying the necessary extra heat and uid.
NAPKIN RASH
Several different skin disorders localize to the napkin area, which is perhaps not surprising when the physical assault that the wearing of napkins provides is considered.
228
Infancy
Figure 14.2 Erosive

napkin dermatitis. Note
sparing in the exures.
Erosive napkin dermatitis
This is the commonest type of napkin dermatitis. Red, glazed, ssured and even
eroded areas develop on the skin at sites in contact with the napkin (Fig. 14.2). The
exures are mostly spared, with the worst areas appearing on the convexities. There
is often a strong ammoniacal smell when the napkin is removed. This is due to the
release of ammonia from the action of the urease released from the faecal bacteria
on the urea in the urine.
The condition responds to nursing without napkins for 2 or 3 days, but if this is
not possible, more frequent napkin changes, the use of soft muslin napkins and
avoidance of abrasive towelling napkins help, as do efcient disposables that leave
the skin surface dry. An emollient washing agent and an emollient used 2 or 3 times
per day also help. Topical 1 per cent hydrocortisone ointment twice daily could be
used if the condition proves resistant.
Case 13
Casey was the rst child born to June. At the age of 412 months, a nasty,
bright-red rash developed on the convexities of her buttocks. This erosive napkin
dermatitis healed quite rapidly when June followed the advice she was given to
use only either good-quality, disposable napkins or soft, muslin napkins and to
change them more frequently. The use of an emollient also seemed to help.
Scaling, red areas develop, mainly in the folds of the skin, although the eruption
overows on to other areas in the napkin area. When the condition is severe and
angry, other sites such as the scalp, face and neck may be affected (Fig. 14.3). The
involved sites may also crack and become exudative. The same kind of care of the
napkin area as outlined above for erosive napkin dermatitis should be advised.
229
Figure 14.3 Napkin dermatitis of

seborrhoeic dermatitis type.
In addition, the use of a weak topical corticosteroid in combination with broadspectrum antimicrobial compounds such as an imidazole (e.g. miconazole or
clotrimazole) should be used twice daily. The involvement of the yeast Candida
albicans in this form of napkin dermatitis has been claimed but not conrmed.
Napkin psoriasis
This is an uncommon, odd, psoriasis-like eruption that develops in the napkin

area and may spread to the skin outside (Fig. 14.4). Treatment should once again
be directed to better hygiene. Weak topical corticosteroids and emollients used as
indicated above usually improve the condition quite quickly.
ATOPIC DERMATITIS (see also Chapter 8)

The condition rarely starts before 46 weeks of age and usually begins between the
ages of 2 and 3 months. It may rst show itself on the face, but spreads quite quickly
to other areas, although the napkin area is conspicuously spared presumably as a
result of the area being kept moist. The ability to scratch develops after about
6 months of age and the appearance of the disorder alters accordingly, with excoriations and lichenication. At this time, the predominantly exural distribution
of the disorder begins, with thickened, red, scaly and excoriated (and sometimes
crusted and infected) areas in the popliteal and antecubital fossae. Emollients
are important in management and mothers should be carefully instructed on
their benet and how to use them. Similarly, bathing should be quick dunks in
230
Infancy
Figure 14.4 Napkin

psoriasis.
lukewarm water, with patting dry, rather than long-lasting hot scrubs with vigorous towelling afterwards. Weak topical corticosteroids only should be used 1 per
cent hydrocortisone and 0.1 per cent clobetasone butyrate are appropriate.
Preparations of 1 per cent hydrocortisone containing urea are helpful.
CRADLECAP
The newborn often develop yellowish scale over the scalp with very little other
abnormality apparent. This has no special signicance and usually disappears
after a few weeks. Application of olive oil or arachis oil with 2 per cent salicylic
acid and shampooing with baby shampoos hasten its removal.
INFANTILE ACNE
It is not uncommon for infants a few months old to develop seborrhoea, comedones, supercial papules and pustules on the face (Fig. 14.5). This infantile acne
has no special signicance, other than that maternal androgens have caused the
infants sebaceous glands to enlarge and become more active. When the disorder
develops in later infancy and is severe, the possibility of virilization due to an
231
Figure 14.5 Infantile acne showing

numerous acne spots affecting the cheeks
and forehead.
endocrine tumour or adrenocortical hyperplasia has to be considered. Other signs

of androgen over-activity, such as precocious muscle development and male distribution of facial and body hair, should be sought.
Although the disorder usually subsides within a few weeks, it can be unpleasantly persistent. Rarely, deep nodules and even cysts develop.
Treatment with mild topical agents is usually sufcient, e.g. 0.05 per cent
tretinoin gel or 5 per cent benzoyl peroxide gel.
TOXIC EPIDERMAL NECROLYSIS (STAPHYLOCOCCAL

SCALDED SKIN SYNDROME)
There are two different severe disorders that share some features as well as the
name toxic epidermal necrolysis. The rst is covered in Chapter 6 and is a reaction
to certain drugs. The other, which is seen in early infancy and is better termed the
staphylococcal scalded skin syndrome, is described here. It affects infants in the
rst few weeks of life, but can occur in older children. There is a widespread erythematous eruption with striking desquamation of large areas of skin, as in a scald
or burn. There may be a slight fever and some systemic disturbance, but usually the
children are not severely ill, although there is a 23 per cent mortality. The disorder
is due to a particular phage type of Staphylococcus aureus (phage type II), which
releases an erythematogenic exotoxin. This toxin can be shown experimentally to
cause shedding of the most supercial part of the epidermis and stratum corneum
in the skin of the newborn.
232
Old age
(a)
(b)
Figure 14.6 (a) and (b) Lip-licking cheilitis.
Treatment should be with an appropriate systemic antibiotic such as ucloxacillin. The skin should be managed as for a burn, and concern over heat loss,
dehydration and severe infection is necessary.
LIP-LICKING CHEILITIS
Children aged 48 years develop an area around the mouth which becomes sore,
red, scaly and cracked (Fig. 14.6). It is due to licking the lips and the skin around
the lips, which become irritated and dry and are then licked to moisten them,
making the situation worse. The treatment is to explain patiently the nature of the
problem to mother and child and to use an emollient on the affected area.
JUVENILE PLANTAR DERMATOSIS

This disorder has apparently become more common in recent years, affecting
children aged 612 years predominantly. It is a type of eczema that affects the
soles of the forefeet and the toes. The affected skin becomes glazed, scaly and
cracked, and the condition tends to be very persistent. Treatment with emollients,
topical corticosteroids and weak tar preparations is recommended, but the disorder tends to resist treatment and eventually remits spontaneously.
Old age
There is a growing acreage of elderly skin because of the staggering increase in the
proportion of the population over the age of 60 years. The increase in longevity
since the beginning of the twentieth century is approximately equal to that seen
in the human race in the previous 5000 years. We certainly need to know more
about the ageing process and its effects on the skin.
233
THE AGEING PROCESS

Very little is known as to why tissues age. Generally, we distinguish between
intrinsic ageing and extrinsic ageing. The latter is not true ageing, i.e. the effects
of the passage of time alone on the tissues, but the results of cumulated environmental trauma. As far as the skin is concerned, the most signicant environmental trauma stems from solar radiation in the form of ultraviolet radiation (UVR:
see page 27).
There are many hypotheses to account for intrinsic ageing, which range from a
kind of built-in obsolescence within the DNA molecule itself to the cumulated
results of metabolic damage from active oxygen species and free radicals. Whatever
the explanation, at present there is very little that can be done to stem the tide of
the passing years, other than carefully choosing long-lived parents! Another inexplicable aspect of ageing is its variability. There are enormous variations in the rates
at which different individuals age, as well as major differences in the rates at which
individual organs and systems age within one individual.
SKIN CHANGES IN THE ELDERLY

Structural changes
Both the epidermis and the dermis become thinner on non-light-exposed sites
with the passing of the years. The degree of thinning is variable, but, between the
ages of 20 and 80, dermal thickness on the exor aspect of the forearm changes in
men from a mean of 1.1 mm to 0.8 mm. The epidermis thins from four to ve cells
thick at age 20 to approximately three cells thick at age 80. The individual keratinocytes also shrink with age, although the horn cells at the surface inexplicably
increase in area. Interestingly, the stratum corneum does not appear to change substantially in thickness during ageing.
Blood vessels decrease in number with age, but thicken. Adnexal structures also
decrease in size and number with increasing age. This applies also to the hair
(see page 268), but not always to the sebaceous glands, as on the face they may,
paradoxically, enlarge, which is sometimes clinically evident in the condition of
sebaceous gland hyperplasia (see page 188).
The dermal connective tissue loses much of its proteoglycan ground substance
and the collagen bres become mainly tough, insoluble and heavily cross-linked
biochemically. Pigment cells become fewer in number and smaller, and Langerhans
cells are also less in evidence in the skin of the elderly.
Functional changes
Wound healing is slower and may be less complete in the elderly. The aged
also respond less vigorously to chemical and physical trauma the erythema
and swelling are less marked and slower to develop. Delayed hypersensitivity is
depressed and this also applies to other components of the immune response.
234
Old age
The activity of the pigment cells is depressed, and non-exposed areas of skin
are in general paler in the elderly than in young and mature subjects. On exposed
areas of skin, melanocytes show irregular increases in pigmentation.
Sweat gland responses to heating decrease, and the rate of sebum secretion also
decreases, although this is less marked than many other functions in the elderly.
Sensory discrimination decreases in the elderly, but, unfortunately, not the sensations of itch or pain!
SKIN DISEASE IN THE ELDERLY

There are very few skin disorders that are specic to the elderly. However, there are
many disorders that are more common in the aged, and others that have a different natural history and appearance.
Dry and itchy skin
As the skin ages, it becomes drier and tends to become itchier. This tendency is
heightened by:
low relative humidity

frequent hot bathing and vigorous towelling
low ambient temperature.
The itchiness can be disabling and it is important to try to reduce the desiccating stimuli to which the skin is exposed. The generous use of emollients as topical applications as cleansing agents and of bath additives is mandatory.
Although itchiness due to dry skin in the elderly is quite common, it has to be
remembered that scabies and the other causes of generalized pruritus also occur
in this age group and should be diligently sought.
Eczema
Eczema is a common problem in one form or another in the elderly. It is dealt

with in Chapter 8, but some points are worth emphasizing here. In most cases, no
cause is found for the development of eczema, particularly in elderly people, in
whom it can spread rapidly and become extremely disabling.
Atopic dermatitis is uncommon in the elderly and is as trying and uncomfortable
as at other times of life when it does occur.
Discoid eczema is a form of constitutional eczema that is more common in the
elderly.
Eczema craquele is an eczematous disorder that is virtually specic to the skin
of the elderly, occurring against a background of generalized xerosis, or drying of
the skin surface.
Photosensitive eczema is more common in elderly men and is often very persistent, causing great difculties in its management.
Minor degrees of seborrhoeic dermatitis are very common in the elderly and
occasionally the disorder can spread to become generalized.
235
Treatment
The treatment of eczema in the elderly is similar to that in other age groups.
However, emollients are even more important and there should be greater readiness
to use systemic remedies, including cyclosporin, azathioprine and corticosteroids.
Case 14
William was 83 and lived by himself. His winter bronchitis worsened one day and
he developed pneumonia. After being in hospital for 4 days, his chest improved
with the use of antibiotics, but he began to develop an odd, itchy, crazy paving
pattern of rash on his shins. This eczema craquele was due to the increased
washing and decreased humidity in the hospital. It responded to reduced rubbing
and scrubbing and the use of emollients.
Skin tumours
Skin tumours are a frequent reason for the elderly consulting a physician.
Seborrhoeic warts are found in virtually everyone over the age of 60 years and,
although benign, often result in minor symptoms and some cosmetic embarrassment. They can easily be removed by curettage and cautery, but when present in
large numbers, can present an insoluble problem. Solar keratoses are another frequent cause of presentation some 4 per cent of all new patient consultations in
the dermatology department of the University Hospital of Wales were for solar keratoses. Although very few progress to squamous cell cancer, they indicate that serious solar damage has occurred and that more signicant lesions may develop. They
are uncommon below the age of 45 years and very common over the age of 60
years. As with seborrhoeic warts, solar keratoses may also cause minor symptoms
and some cosmetic problems.
Basal cell carcinomas (see page 214) are almost as common as solar keratoses.
Because of their capacity for local invasion and tissue destruction, they cause
considerable morbidity. Squamous cell carcinomas (see page 211) are much less
common, but can metastasize as well as cause local tissue destruction. Malignant
melanoma (see page 219) is slightly more common in the elderly compared to
young age groups, but lentigo maligna (see page 219) is virtually restricted to the
elderly.
Management of skin disorders in the elderly
Through no fault of their own, the elderly are often physically, socially and economically deprived. Their housing, hygiene, nutrition, clothing and means of
heating may all be decient, and this should be taken into account when designing treatments. If they live alone, as is often the case, they may well be unable to
nd anyone to help with the application of ointments to body parts they cannot
reach themselves or to assist with bandages because of lack of mobility.
It must be remembered that the elderly may also have difculty in hearing,
understanding and/or remembering instructions, especially if these are complex
236
Summary
and involve more than one medicament. If possible, instructions on the medications should also be given to an accompanying relative or legibly written out.
The above potential difculties need to be taken into account when trying to
help an elderly patient with a skin problem.
Summary
Neonatal skin is not mature functionally, so that
excess water loss may occur, leading to dehydration.
Similarly, the barrier of infants skin is less efcient
than in adult life, permitting greater amounts of
topically applied agents to be absorbed. Infant skin
is also less able to withstand infection.
Rashes in the napkin area may be due to
erosive dermatitis on the convexities from
persistent skin contact with faeces and urine or
due to seborrhoeic dermatitis where the rash is
mainly in the exures. It may also be psoriasiform
in type, although the relationship of this to adult
psoriasis is uncertain. Frequent changes of nappies
and the use of softer materials, together with the
use of emollients and emollient cleaners and, if
required, hydrocortisone, will rapidly improve most
affected infants.
Atopic dermatitis starts at 24 months, with rash
on the face at rst. The ability to scratch does not
develop before 6 months of age, when the
distribution and appearance of the rash change.
Flexural lesions and excoriations start to develop.
Advice on bathing and the frequent use of
emollients and weak corticosteroids should help.
Infantile acne with seborrhoea, comedones, papules
and pustules is not uncommon and may be
persistent. If it develops late in infancy, look for
other signs of virilization (such as muscle growth).
The staphylococcal scalded skin syndrome occurs
in young infants and is a type of toxic epidermal
necrolysis. It is caused by the erythematogenic
toxin of a particular phage type of Staphylococcus

aureus (phase type II). The rash is red and peeling
and is accompanied by mild fever and some
systemic disturbance.
Lip-licking cheilitis is a perioral rash caused by
licking the skin around the mouth. Juvenile plantar
dermatosis is an eczematous rash of 612-year-old
children affecting the forefeet.
Apart from the intrinsic ageing process which all
tissues undergo, the skin also experiences
cumulative damage from the environment,
particularly solar UVR, which we incorrectly identify
as due to ageing. Intrinsic ageing is of unknown
cause and is variable in rate and severity.
Both the epidermis and dermis thin with age,
losing about one-third of their thickness by the
age of 80. Blood vessels, adnexae and pigment
cells are all reduced in ageing. In addition, wound
healing slows and the immune defences diminish.
Dry, itchy skin is common in the elderly. Eczema
craquele, photosensitive eczema and discoid
eczema are more common in this age group.
Seborrhoeic dermatitis is also common in the
elderly.
Seborrhoeic warts are very common in the elderly
and may be present in large numbers. Solar
keratoses also increase with age. Basal cell
carcinoma, squamous cell carcinoma and
melanoma are all more common in the elderly
(see Chapter 13). The elderly often have difculty
coping with instructions given for treatment.
237
C H A P T E R
15
Pregnancy and
the skin
238
240
240
241
Summary
242

PIGMENTATION
Most women develop a generalized increased pigmentation of the skin notable in
the midline of the abdomen, converting the linea alba into the linea nigra. The
areolae of the breasts change in colour from pink to brown and the skin of the
external genitalia also darkens.
In addition, dark areas appear symmetrically across the cheeks, around the eyes
and over the forehead, giving a mask-like appearance (Fig. 15.1). This is known
as melasma (or chloasma) and seems much more common and troublesome in
darker, Mediterranean and Asian skin types. The same problem is sometimes seen
in non-pregnant women and it is claimed that the contraceptive pill is responsible. Some 60 per cent of pregnant women develop some melasma, and 30 per cent
of women on the pill do so.
The commonest type of melasma is centrofacial (about 65 per cent). The
malar type, with pigmentation on the cheeks, and the mandibular pattern, with
pigmentation along the lower jaw, are less common.
The increase in blood levels of melanocyte-stimulating hormone and the consequent stimulation of melanocyte activity or the increase in oestrogen and progesterone may be involved in the cause.
Pigmented moles also darken during pregnancy and new moles may appear
both causing concern.
238
Figure 15.1 Mask of pregnancy, also

known as melasma or chloasma.
Figure 15.2 Stretch marks, or striae distensae, on

the abdomen 6 months postpartum.
STRIAE GRAVIDARUM
Striae distensae (or stretch marks) are linear areas of apparent atrophy of the skin
due to disruption of dermal connective tissue bres (Fig. 15.2) as a result of ruptured dermal elastic bres. They occur at sites of skin stretching when there is
excess glucocorticoid activity. They occur normally in early adolescence, in
Cushings syndrome after both systemic and topical corticoid therapy, and in
pregnancy, when they are called striae gravidarum.
Striae gravidarum occur predominantly over the lower abdomen and over the
breasts during the third trimester and are of major cosmetic concern.
CUTANEOUS VASCULARITY
One of the oddest of phenomena that occur in pregnant women is the appearance
of small vascular malformations known as spider naevi (Fig. 15.3). These only
develop on the face, upper trunk and arms, i.e. the area of drainage of the superior vena cava. As with liver disease, in which these lesions also occur, it may be that
in pregnancy there is a relative excess of oestrogenic activity that provokes these
vascular anomalies. Also, the palms in pregnancy become redder and feel warmer,
as in liver disease. Both the spider naevi and the palmar changes fade following
delivery.
Figure 15.3 Spider naevus.

239
Pregnancy and the skin
PRURITUS IN PREGNANCY
Generalized itching is sometimes a problem for pregnant women. In some
instances, there appears to be intrahepatic cholestasis leading to biliary retention
in the last trimester. There is little that can be done concerning this problem, other
than using emollients and mentholated oily calamine preparations.

Common inammatory skin disorders such as psoriasis and atopic dermatitis
often improve during pregnancy, but this is by no means invariable. Systemic
lupus erythematosus is reputed to worsen. Great care must be taken with systemic
medication during pregnancy. Systemic retinoids are very teratogenic and should
not be given to women in the reproductive age group unless they take reliable contraception. Other drugs such as antibiotics and hormones should also be avoided.
Topical treatments must also be assessed for their teratogenic potential. Most
topically applied materials are absorbed to a greater or lesser extent and, at least
theoretically, could constitute a risk to the fetus. The possibility that topical
tretinoin could be responsible for fetal malformations after usage for acne has
been extensively investigated, but discounted because insufcient is absorbed
through the skin. Fortunately, this applies to most of the routine topical agents
used for psoriasis, eczema and acne providing the affected area does not amount
to 10 per cent or more of the body surface area.

The fetus is occasionally affected by skin disorders in the mother.
THE INHERITED GENODERMATOSES

Genetic faults may be passed on and phenotypically expressed in the child. This is
obvious with dominant disorders such as some of the ichthyoses (see page 246).
IMMUNOLOGICALLY MEDIATED DISEASES

In some disorders, pathogenetic antibodies cross the placenta and cause disease in
the fetus. This may be the case in lupus erythematosus and, in one rare variety of
this condition, congenital heart block can be induced in the child. It may also
occur in the rare blistering condition of pemphigus. In most of these cases, the
fetal skin disorders only last as long as the transplacentally transmitted antibodies
in the newborn childs circulation.
240
INFECTIONS
These are of most concern now with regard to human immunodeciency virus
(HIV) infection, and frighteningly high rates of HIV positivity have been found
in pregnant women in some communities. Syphilis may still be a problem if undiagnosed and then transmitted congenitally. Other infective skin disorders that may
be passed from mother to fetus include chickenpox, herpes simplex, candidiasis
and warts, although the last two are better classied as intranatal infections, as
they are caught from the birth passages.

ITCHY RASHES IN THE LAST TRIMESTER
Several patterns of itchy, erythematous rash occur in the last trimester of pregnancy. Their causes are unknown, they are transient, remitting spontaneously
before delivery or, at worst, shortly afterwards, and they produce much discomfort. In some cases, they are associated with pre-eclamptic toxaemia.
The rash mostly occurs over the abdomen and anks, but also appears on the
upper limbs. The lesions are mainly micropapules, but in some patients red,
urticaria-like plaques develop (Fig. 15.4). Annular and odd gurate lesions may also
occur. Treatment is symptomatic, with emollient or weak topical corticosteroids.
Figure 15.4 Common itchy

erythematous eruption of
pregnancy.
Case 15
Charlotte, aged 24, is 7 months pregnant with her rst child and has suddenly
developed an itching, red rash on her abdomen, buttocks and thighs. Apart from
striae and midline pigmentation, there are only a few nondescript papules to see.
This is the common maculopapular rash of pregnancy, which will quickly subside
when she has been delivered and will obtain some relief from simple emollients.
HERPES GESTATIONIS (PEMPHIGOID GESTATIONIS)

This is an uncommon, extremely irritant, blistering rash, occurring in the last
trimester of pregnancy. The eruption starts on the anks or over the abdomen
with itchy urticarial papules and vesicles and blisters (Fig. 15.5). The blistering is
subepidermal and is quite similar to that seen in senile pemphigoid (see page 88).
There is often a circulating antibody directed to the dermoepidermal junctional
area, although this is present in low titre.
The rash usually remits shortly after birth, but may recur in subsequent pregnancies or even after taking oral contraceptives. Treatment should be conned to
topical applications in the rst instance. If this does not help, dapsone may be
tried for short periods.
Figure 15.5 Blistering rash

due to pemphigoid
gestationis.
241
Pregnancy and the skin
Summary
The breast areolae, the midline of the abdomen, the
external genitalia and areas on the face become
hyperpigmented during pregnancy. The facial
changes, known as melasma, occur in 60 per cent
of pregnant women.
Striae distensae (or stretch marks) occur in
Cushings syndrome, during treatment with
corticosteroids, in pregnancy (striae gravidarum) and
in normal adolescence.
Spider naevi may develop during pregnancy.
Generalized itching may occur during the third
trimester due to intrahepatic cholestasis.
Inammatory dermatoses may either improve or
worsen during pregnancy. Great care should be
taken to ensure that the developing fetus is not
exposed to potentially teratogenic drugs, whether

administered systemically or topically to the
pregnant woman.
The fetus may be affected by genodermatoses,
by immunodermatoses because of transplacental
carriage of pathogenic antibodies (e.g. pemphigus)
or infection from transplacental spread of infection
such as HIV, syphilis and chickenpox, or from
intranatal contamination, e.g. wart virus.
Various transient, itchy rashes occur in the last
trimester of pregnancy. In addition, a very itchy,
blistering rash occurs in the last trimester
associated with a circulating antibody, which remits
after delivery but may recur in subsequent
pregnancies.
242
Disorders of
keratinization and other
genodermatoses
C H A P T E R
16
Introduction
243
Xeroderma
245
246
247
249
251
Lamellar ichthyosis
252
Collodion baby
252
254
256
Summary
257
Introduction
EPIDERMAL DIFFERENTIATION
The differentiation process in which basal epidermal cells gradually mature and
transform into stratum corneum cells is known as keratinization. In this process,
which takes about 14 days, plump, cuboidal or spheroidal, hydrated, highly metabolically active cells gradually become tough, hardened, biochemically inactive,
thin, shield-like structures that are programmed to desquamate off the skin surface (Fig. 16.1). This process is biochemically complex and it is not surprising that
it is subject to genetically determined errors. During keratinization, a tough,
chemically resistant, cross-linked protein band is laid down just inside the plasma
membrane and the whole cell attens to a thin disc (corneocyte, Fig. 16.2). The
corneocytes water content is reduced from the usual 70 per cent to 30 per cent
and most of the cellular organelles, including its nucleus, are eliminated. The keratinous tonolaments become organized in bundles and are spatially orientated.
A further characteristic feature of the normal stratum corneum is the presence of
an intercellular cement material that contains non-polar lipid and glycoprotein.
243
Disorders of keratinization and other genodermatoses
Figure 16.1 Corneocyte desquamating from the skin

surface as seen by scanning electron microscopy.
Figure 16.2 Single corneocytes as seen by phase

contrast microscopy.
STRATUM CORNEUM FUNCTION

The stratum corneum is the major barrier to water loss from the skin and to the
penetration of chemical agents that come into contact with the skin. It also provides some mechanical protection and prevents penetration by microbes.
SCALING
A scale is merely an aggregate of horn cells that have failed to separate from each
other in desquamation, and the condition of hyperkeratosis is an exaggeration of
this problem. Thus, regardless of the particular metabolic fault ultimately responsible, the nal common pathogenetic pathway is a failure in the normal loss of
intercorneocyte binding forces (cohesion) in the supercial portion of the stratum corneum.
ICHTHYOSIS
The term ichthyosis (meaning sh) is unfortunate, as the scale of modern sh is,
in fact, mesodermal rather than ectodermal in origin. The term ichthyosis is used
to describe generalized, non-inammatory disorders of keratinization and
implies a congenital origin. However, there are many exceptions!
DISABILITY IN DISORDERS OF KERATINIZATION

Contrary to popular (both lay and medical) belief, skin diseases can be very disabling. There is a primitive revulsion at a disordered skin surface, which results in
signicant isolation and social and emotional deprivation. Patients with chronic
244
Xeroderma
skin disorders often become severely depressed. Also, it is not often appreciated
just how severely physically disabled some patients with skin disease are. The
abnormal scaling and hyperkeratotic skin does not have the normally excellent
extensibility and compliance, so that movements are limited.
Xeroderma
Xeroderma does not represent a single disease process. The term derives from the
Greek xeros, meaning dry, and xeroderma just means dry skin. In fact, xeroderma
is used to describe scaliness rather than water content. Because the appearance of
scaling transiently disappears if the abnormal skin is hydrated, it has mistakenly
been believed that scaling is the manifestation of water deciency.
CAUSES
There are some normal individuals who tend to have a dry skin and they are
more susceptible to stimuli that provoke scaling of the skin surface. Ageing tends
to make the surface of the skin feel drier and this seems to be associated with pruritus in susceptible individuals. A low relative humidity aggravates the problem, as
does repeated vigorous washing, especially in hot water with some soaps and
cleansing agents. Presumably, the toilet procedures leach out important substances that are vital to the integrity of the stratum corneum. Xeroderma tends to
be worse in the wintertime and, when accompanied by itching, is known, logically
enough, as winter itch. This is particularly a problem in the north-eastern USA
because of the low relative humidity.
Xeroderma is seen in many patients with atopic dermatitis. It has been suggested that this is a manifestation of ichthyosis, but there is more evidence in
favour of the disorder being the result of the eczematous process itself. Xeroderma
is also seen during the course of severe wasting diseases such as carcinomatosis,
intestinal malabsorption and chronic renal failure, but should not be confused
with acquired ichthyosis (Table 16.1).
Table 16.1 Precipitating causes of acquired ichthyosis
Precipitating cause
Comment
Hodgkins disease and other

reticuloses
Rarely, other neoplastic diseases
Essential fatty acid deciency
Due to dietary deciency, blind loop syndrome,

or intestinal bypass operation
Serum lipid-lowering drugs
For example, nicotinamide, butyrophenones
Leprosy
Usually subsequent to treatment
AIDS
Accompanied by severe pruritus
245
KERATOSIS PILARIS
Horny plugs occur in the hair follicles of the outer aspect of the upper arms, forming sheets of pink, horny papules (Fig. 16.3), and occasionally on the thighs. It is
seen in ordinary xeroderma, in autosomal dominant ichthyosis, and sometimes
in normal young women for no apparent reason.
TREATMENT
Figure 16.3 Keratosis

pilaris. Horny red papules on
the upper arms.
Patients should be instructed to shower rather than bathe, to use lukewarm water
rather than hot water, to use emollient cleansing agents rather than ordinary
soaps, and to pat dry rather than vigorously towelling after bathing. If the patient
lives in centrally heated rooms, humidiers should be employed to raise the relative humidity. Emollients are a mainstay of treatment (see page 306). These act
by supplying an oily lm on the skin surface to prevent evaporation of water and
encourage a build-up of this in the skin. Emollients act for a short time only up
to 23 hours at most and need to be frequently applied. Their action can be
supplemented by bath oils, which deposit a lm of lipid on the skin surface.

DEFINITION
This is a common disorder of keratinization, characterized by mild generalized
scaliness clinically and reduction of the granular cell layer histologically, which is
inherited in an autosomal dominant manner.
CLINICAL FEATURES
There is widespread ne scaling over the skin surface, which tends to be worse in
the wintertime when the humidity is low. It spares the exures and is most noticeable over the extensor aspects of the limbs and trunk, being most noticeable over
the back, the lateral aspects of the upper arms, the anterolateral thighs and particularly the shins (Fig. 16.4). Keratosis pilaris may be seen over the outer aspects
of the upper arms in a few subjects. The condition is hardly noticeable in
most people, but is quite marked and disabling in a few. In the worst affected,
large, polygonal, dark scales form on the shins. The disorder is lifelong, but may
worsen in old age.
PATHOLOGY AND AETIOPATHOGENESIS

The condition is inherited as an autosomal dominant disorder, but the biochemical basis is unclear. It has been estimated that the gene occurs with a frequency of
246
Figure 16.4 Moderately severe scaling

in autosomal dominant ichthyosis.
Figure 16.5 Pathology of autosomal dominant

ichthyosis. Note the virtual absence of granular
cell layer.
1 in 500. Histologically, the only abnormality detectable is a much diminished

granular cell layer (Fig. 16.5).
Ultrastructurally and biochemically, there is decreased content of a basic histidinerich protein known as laggrin, which is important in the orientation of the keratin
tonolaments.
TREATMENT
Generally, little is required in the way of treatment other than emollients. Patients
who have very severe scaling may be helped by the use of topical keratolytic
agents, including preparations containing urea (1015 per cent) and salicylic acid
(16 per cent). The latter is particularly effective in encouraging desquamation,
but may not be used on large body areas for any length of time, as salicylic acid
preparations when applied to abnormal skin may cause salicylate intoxication (salicylism). Concentrations of more than 2 per cent may also irritate the skin.
DEFINITION
This is an uncommon, moderately severe disorder of keratinization that is inherited
as a sex-linked characteristic in which the underlying metabolic fault is deciency
of steroid sulphatase.
247
Figure 16.6 Skin scaling in sex-linked

ichthyosis.
CLINICAL FEATURES
The male children who are born with this disorder are often the products of postmature pregnancies and difcult labours. The reason for this appears to be a placental deciency of the steroid sulphatase and a consequent failure of the usual
splitting of circulating maternal oestrone sulphate in the last trimester of pregnancy.
The free oestrone is thought to have a role in priming the uterus to oxytoxic stimuli.
The scaling is usually more severe than in autosomal dominant ichthyosis
(Fig. 16.6). It is also more marked over the extensor aspects of the body surface,
but does not always spare the exures and often affects the sides of the neck and even
the face. The scales are often quite large, particularly over the shins and have a
dark-brownish discoloration. Patients with sex-linked ichthyosis may be signicantly disabled by their disorder.
ASSOCIATED DISORDERS
There is an association with cryptorchidism and, rarely, even with testicular cancer
on the basis of this. There is also an association with a form of cataract.
PATHOLOGY AND AETIOPATHOGENESIS

The trait is carried on an X chromosome and is recessive, so that it is not manifest in women (XX) who become carriers, but it is in male offspring (XY). In fact,
248
the carrier female may demonstrate patchy scaling that is consistent with the random deletion (or Lyon) hypothesis. The disorder is quite uncommon, having a
gene frequency of approximately 1 in 6000.
Histologically, there is a minor degree of epidermal thickening and mild hypergranulosis. Biochemically, affected male subjects show a steroid sulphatase deciency, but for diagnostic purposes, broblast, lymphocyte or epidermal cell
cultures are tested. The steroid sulphatase abnormality results in excess quantities
of cholesterol sulphate in the stratum corneum with diminished free cholesterol.
This has been used as the basis of a diagnostic test and has been suggested as the
underlying basis for the abnormal scaling.
TREATMENT
Treatment is as for autosomal dominant ichthyosis, but some patients may need
oral retinoids.
Case 16
J.S. presented at the age of 17 with generalized scaling, dry skin. He had had
it since birth, although it didnt start to be a problem until he reached the age of
11. He complained of itchiness especially in the wintertime, when, in addition
to the itch, the skin of his hands became sore and cracked in places. He had
a brother who was affected and his maternal grandfather also had the disease.
Close questioning of his mother revealed that J.S. was born 2 weeks late after
a difcult delivery. It was clear that he had sex-linked ichthyosis, which could
be expected to persist, but the symptoms of which should be helped by
emollients.

Non-bullous ichthyosiform erythroderma (NBIE) is inherited as a rare, autosomal
recessive disorder. It is probably heterogeneous, as, although the skin abnormality
is similar in all patients, there are associations with abnormalities in other organ
systems in some groups of patients.
CLINICAL FEATURES
Characteristically, there is generalized erythema and ne scaling (Fig. 16.7). There
is a history of a collodion membrane (see page 252) in a few patients. Ectropion,
deformities of the ears and sparsity of scalp hair are common accompaniments.
Neurological and immunological abnormalities occur in some patients. The condition persists throughout life, although the erythema tends to decrease.
249
Figure 16.7 Non-bullous ichthyosiform

erythroderma.
Histologically, there is a psoriasiform hyperplasia and parakeratosis. As in

psoriasis, there appears to be a rapid rate of epidermal cell production. The biochemical basis for this ichthyotic disorder is unknown.
TREATMENT
Topical treatments with emollients and keratolytics as for patients with autosomal
dominant ichthyosis may be sufcient.
Severely affected patients may benet from the use of long-term oral retinoid
drugs. The agent usually used is acitretin, but isotretinoin has been used for some
patients. The dose of these drugs is 0.30.7 mg/kg body weight per day, given in
two divided doses daily with food. The disorder starts to improve after 24 weeks,
but full improvement may not take place before 6 weeks.
The oral retinoids appear to affect the process of keratinization rather than any
particular component of NBIE. Although there is often considerable improvement, evidence of the underlying problem is always present, and the condition
always relapses when treatment is stopped. The oral retinoids have major and
minor toxicities (see page 140) and are markedly teratogenic, so that fertile
women must use effective contraception. Patients must be regularly monitored
for hepatotoxicity, hyperlipidaemia and bone toxicity. Most patients notice drying
of the mucosae of the lips particularly and some an increase in the rate of
hair loss.
250
Bullous ichthyosiform erythroderma

(epidermolytic hyperkeratosis)
Epidermolytic hyperkeratosis is a rare, autosomal dominant disorder of keratinization. As in NBIE, there is generalized erythema and the disorder is presaged
by a collodion membrane at birth in some patients (see page 252). The condition
is characterized by the tendency to blister or develop erosions at the sites of
trauma (Figs 16.8 and 16.9). The erythema and blistering improve with age.
Scaling and hyperkeratosis are characteristically ridged or corrugated at exures.
Patients often present a pathetic picture because of their severe hyperkeratosis,
which causes physical disability and discomfort as well as a socially unacceptable
appearance. In addition, the hyperkeratotic areas often become infected and smell
unpleasant. Ectropion and deformed (crumpled) ears are common.
The pathognomonic histological feature of epidermolytic hyerkeratosis is a
reticulate degenerative change in the epidermis (Fig. 16.10). As in NBIE, there is a
high rate of epidermal cell production. In recent years, mutations in certain
keratin genes have been identied in this disorder.
Topical emollients and keratolytics are not often very helpful. The oral
retinoids may improve the appearance considerably, although the dose has to be
Figure 16.8 Epidermolytic hyperkeratosis showing typical severe hyperkeratosis and scaling.
Figure 16.9 Erosion in epidermolytic

hyperkeratosis following minor injury to
this area.
251
Figure 16.10 Pathology of epidermolytic hyperkeratosis

with reticulate degenerative change.
Figure 16.11 Lamellar ichthyosis, with

marked hyperkeratosis and scaling.
carefully regulated, as these drugs may temporarily increase the blistering as well
as decreasing the hyperkeratosis!
Lamellar ichthyosis
This is a rare, autosomal recessive disorder of keratinization, characterized by a
striking degree of hyperkeratosis but not much erythema. As with NBIE and epidermolytic hyerkeratosis, some patients develop the condition after being born in
a collodion membrane. The hyperkeratosis may be discoloured brown, for reasons
that are unclear (Fig. 16.11). As with the other severe disorders of keratinization,
there may be marked ectropion and ear deformities (Fig. 16.12).
Histologically, there is marked hyperkeratosis and hypergranulosis.
Treatment is similar to that for NBIE and epidermolytic hyperkeratosis, with
oral retinoid drugs being the only available agents that can produce any substantial improvement.
Collodion baby
This is an odd condition in which babies are born covered by a shiny, transparent
membrane (Fig. 16.13). This gradually peels off after a week or so, the peel looking
252
Collodion baby
Figure 16.12 Crumpled ear, seen in

many severe disorders of keratinization.
Figure 16.13 Shiny membrane covering

the skin in a collodion baby.
like collodion hence the name. Ultimately, the child may develop normally or
may develop one of the severe disorders of keratinization discussed above.
Nothing is known of the cause. Collodion babies need to be carefully nursed,
as their skin barrier function may be abnormal, so that they lose much water and
become dehydrated.
HARLEQUIN FETUS
This is a rare and mostly fatal disorder in which the child is born encased in thick,
abnormal, ssured, hyperkeratotic skin. This disorder is also due to abnormalities
of keratin synthesis. Survival of a few of these unfortunate children has been
reported with the use of oral retinoids.
REFSUMS SYNDROME (HEREDOPATHIA ATACTICA

NEURITISFORMIS)
This is a very rare, autosomal recessive, metabolic disorder in which there is, in all
tissues, accumulation of phytanic acid. This fatty acid substitutes for other fatty
acids in membrane lipids, which is probably responsible for many of the clinical
manifestations of the disorder. These manifestations include cerebellar ataxia,
polyneuritis, retinitis pigmentosa, nerve deafness and generalized ichthyosiform
scaling.
253
ACQUIRED ICHTHYOSIS
Generalized skin scaling without accompanying inammation develops in adult
life in this disorder. The most important cause of acquired ichthyosis is underlying malignant disease particularly lymphoma such as Hodgkins disease (see
Table 16.1).

DARIERS DISEASE (KERATOSIS FOLLICULITIS)
Dariers disease is an uncommon disorder that appears to be inherited as an autosomal dominant disorder, but also occurs sporadically.
A characteristic feature is the appearance of groups of brownish, horny papules
over the central trunk, shoulders, face and also elsewhere (Figs 16.14 and 16.15).
These papules easily become irritated and/or infected and become exudative and
crusted. Other features include the presence of tiny pits on the palms and a nail
dystrophy in which there is a vertical ridge starting at an indentation at the nailfree border.
There is a curious loss of cohesion between keratinocytes above the basal layer
a little like the acantholysis seen in pemphigus (see page 91). The suprabasilar
Figure 16.14 Brown keratotic papules

on the trunk in Dariers disease.
Figure 16.15 Red exudative papules on

the chest in Dariers disease.
254
clefting that results is accompanied by an odd form of premature keratinization

in which eosinophilic bodies (corps ronds) and small, dense basophilic bodies
(grains) are formed, to be carried upwards by the epidermis.
Topical treatment with mild keratolytics such as 2 per cent salicylic acid or
0.0250.05 per cent tretinoin may be helpful. Oral retinoids are often of considerable assistance.
HAILEYHAILEY DISEASE (CHRONIC BENIGN FAMILIAL

PEMPHIGUS)
This is a rare, familial disorder with some similarities to Dariers disease. Fissured,
exudative, infected lesions develop in the groins, the axillae and around the neck
in particular. It does not usually start before early adult life and is much worse in
summertime.
TYLOSIS
This term describes a group of disorders in which there is marked thickening
of palmar and plantar skin due to some localized abnormality of keratinization
(Fig. 16.16). The disorder is clearly heterogeneous, with autosomal dominant,
autosomal recessive and sex-linked recessive types being described. There is also a
wide range of clinical features, with involvement of the dorsa of the hands and feet
in some patients and an odd punctate palmar pattern in others.
In one inherited variety, there is a close association with the development of
carcinoma of the oesophagus.
Figure 16.16 Massive palmar

hyperkeratosis in one variety of tylosis.
255
Fortunately, most patients are not as disabled as may be thought from the clinical appearance. As long as they keep their skin surface exible and smooth with
emollients and keratolytics, they can manage everyday activities quite well.
PACHYONYCHIA CONGENITAL
This is a rare, autosomal recessively inherited disorder in which there is striking
thickening of the nails. There are also hyperkeratotic areas over the palms and
sometimes elsewhere.
TUBEROUS SCLEROSIS
Tuberous sclerosis is a rare, autosomal dominantly inherited disorder in which
defects occur in many organ systems.
Major skin abnormalities include the appearance of pink-red papules around
the nose and cheeks, which increase in number during adolescence and are
known, inappropriately, as adenoma sebaceum. Firm, whitish plaques (shagreen
patches) with a cobblestone surface, depigmented leaf-shaped macules and subungual bromata are other skin signs. Cerebral malformations often result in
epilepsy. Renal hamartomas occur in 50 per cent of patients. Mental deciency is
seen in many patients with this disease.
VON RECKLINGHAUSENS DISEASE (NEUROFIBROMATOSIS)

This is a not uncommon, autosomal dominant disorder, but a high frequency of
new gene mutations and variable expression of the disorder make its occurrence
difcult to predict.
THE MAIN FEATURES ARE AS FOLLOWS
Brown macules appear, varying in size and aptly described as caf au lait
patches, characterized by the presence of giant melanosomes. The appearance
of such freckle-like lesions in the axillae is diagnostic of the disorder.
Skin-coloured to pink-mauve compressible, soft skin tumours develop, some
of which are pedunculated (Fig. 16.17). These are neurobromata and may be
present in large numbers, causing a considerable cosmetic disability.
Larger tumours of the limbs occur. These are plexiform neuromas.
The numbers of lesions increase with age. Patients are also subject to the development of a wide range of neoplastic lesions, including acoustic neuroma,
phaeochromocytoma and brosarcoma.
256
Summary
Figure 16.17 A mildly

affected patient with
neurobromatosis. There
is a neurobroma on the
abdomen.
ANHIDROTIC ECTODERMAL DYSPLASIA

In this rare disorder, there are characteristic frontal bosses on the skull as well as
a saddle deformity of the nose. There are no eccrine sweat glands present, so that
individuals are subject to hyperpyrexia in hot weather. The hair may be sparse and
ne and there are multiple abnormalities of the teeth.
Summary
Keratinization involves the transformation of
epidermal cells into tough, thin, shield-like
corneocytes, which make up the stratum corneum
barrier.
Scaling is the result of failure of the nal stage of
keratinization in which corneocytes separate
individually. Thus, a scale is an aggregate of
unseparated corneocytes and occurs in any
disturbance of keratinization congenital or
acquired.
Scaling may cause considerable disability, both
physical and psychological. Xeroderma just means
dry skin which is, in fact, scaling skin and due to
a wide variety of disturbances of keratinization.
Xeroderma is common in the elderly and in atopic
eczema and is worse in low relative humidity such
as in wintertime.
Treatment of xeroderma is focused on the frequent
use of emollients and emollient cleansers as well
as on gentle showering rather than bathing.
Autosomal dominant ichthyosis is characterized by
generalized ne scaling that is worse on the
extensor surfaces. It may be accompanied by

keratosis pilaris, in which there are horny plugs in
the hair follicle canals. Its frequency is 1 in 500.
Its biochemical basis is uncertain. Emollients and,
if necessary, keratolytics may help some patients
who need them.
The scaling in sex-linked ichthyosis is more
pronounced. Affected males are often born postmature and with difculty. The metabolic basis is
steroid sulphatase deciency, which can be
detected in broblast, epidermal or lymphocyte
culture. Women are carriers of this sex-linked,
recessive gene, which has an overall frequency of
1 in 6000.
Non-bullous ichthyosiform erythroderma is a rare,
autosomal recessive condition, characterized by
generalized erythema and ne scaling. Oral acitretin
helps some patients, although there may be severe
adverse side effects.
In the rare bullous ichthyosiform erythroderma
(also known as epidermolytic hyperkeratosis), there
is generalized erythema, corrugated hyperkeratosis
257
and the tendency to blister. There is a characteristic

reticulate degenerative change in the upper epidermis.
The disorder is dominantly inherited and due to
certain keratin gene mutations. Oral retinoids may
improve the appearance, but at the same time may
increase the blistering.
Lamellar ichthyosis is a rare, autosomal recessive
disorder marked by hyperkeratosis and scaling.
Patients with non-bullous ichthyosiform
erythroderma, epidermolytic hyperkeratosis and
lamellar ichthyosis may be born in a collodion
membrane. This shiny, transparent membrane peels
off after a week or so. It may also rarely occur in
normal infants. Its presence signies compromised
barrier function and affected children need careful
nursing.
Acquired ichthyosis may occur in reticulosis, human
immunodeciency virus (HIV) disease, leprosy,
essential fatty acid deciency and with the use of

some lipid-lowering drugs.
Dariers disease is an uncommon disorder,
occurring either as a autosomal dominant condition
or sporadically. Typically, brownish, crusted papules
occur over the face and upper trunk alongside
palmar pits and a nail dystrophy. Histologically,
suprabasilar clefting and premature keratinization
are evident.
Tuberous sclerosis is a rare, autosomal dominant
condition in which many abnormalities occur. The
presence of pink-red papules around the nose and
cheeks is characteristic.
Von Recklinghausens disease (neurobromatosis)
is a not uncommon, autosomal dominant disorder in
which large numbers of pinkish, compressible, soft
skin tumours develop. Brown macular caf au lait
patches accompany the condition.
258
Metabolic disorders
and reticulohistiocytic
proliferative disorders
C H A P T E R
17
Porphyrias
259
265
266
Summary
267
Porphyrias
The porphyrias are a group of disorders of metabolism of the haem molecule.
Acute, intermittent porphyria has no skin manifestations. Porphyrias that demonstrate skin disorder as a component are summarized in Table 17.1.
PORPHYRIA CUTANEA TARDA

Porphyria cutanea tarda (PCT) is a so-called hepatic porphyria. There is a genetic
component to the disorder, although it has not been completely characterized. It is
much more common in those with alcoholic liver disease, but has also been seen
in patients with liver tumours and those with hexachlorbenzene poisoning.
Metabolic basis
There appears to be a defect in the action of the enzyme uroporphyrinogen decarboxylase, resulting in the accumulation of uroporphyrins and coproporphyrins in
the blood, stools and urine.
Clinical features
When associated with alcoholic liver disease, the disorder is more often seen in
middle-aged men. The characteristic features are seen in the light-exposed areas.
In the early stages of the disease, blistering and fragility of the skin on the face and
backs of the hands are noted (Fig. 17.1). The affected areas also develop an odd
259
Metabolic disorders and reticulohistiocytic proliferative disorders
Table 17.1 Enzyme defects in porphyrias with cutaneous manifestations

Disorder
Enzyme affected
Inheritance
Porphyria cutanea tarda

(cutaneous hepatic porphyria)
Uroporphyrinogen
decarboxylase
Autosomal dominant/
acquired
Variegate porphyria
Protoporphyrinogen
oxidase
Autosomal dominant
Erythropoietic porphyria
(Gunthers disease)
Uroporphyrinogen
cosynthetase
Autosomal recessive
Erythropoietic protoporphyria
Ferrochelatase
Autosomal dominant
Figure 17.1 Porphyria

cutanea tarda. Note
the eroded areas in the
light-exposed skin of the
backs of the hands.
pigmented and mauve, suffused appearance (Fig. 17.2). Later, increased hair growth
occurs on the involved skin and a sclerodermiform thickening of the skin develops.
The diagnosis is made by nding increased uroporphyrins and coproporphyrins
in the stools and urine. If available, monochromatic testing (to irradiate the skin
with very narrow wavelength bands of light or ultraviolet radiation) will reveal
photosensitivity at 404 nm.
The enzyme defect results in abnormal amounts of the metabolites uroporphyrin

III and coproporphyrin III accumulating in the tissues. These substances are
responsible for the photosensitization. Iron overload is also a frequent accompanying feature. Histologically, the blistering is subepidermal and, in the long-standing
case, brosis develops and deposits of immunoglobulin are found perivascularly.
Treatment
The objective is to reduce the circulating levels of porphyrins. This is achieved by

regular venesection removing a pint of blood at a time every 2 or 3 weeks, or
by the use of chloroquine orally, resulting in the secretion of large amounts of
porphyrins in the urine.
260
Porphyrias
Figure 17.2 Suffused, slightly pigmented

and hairy area on the upper cheek and
the area lateral to the orbit in a patient
with porphyria cutanea tarda.
PORPHYRIA VARIEGATA
This is a very rare combination of PCT and acute intermittent porphyria. The
latter is caused by a deciency of delta-aminolaevulinic acid synthetase and is precipitated by certain drugs and anaesthesia, amongst other things.
ERYTHROPOIETIC PROTOPORPHYRIA
Erythropoietic protoporphyria is a very rare, autosomal dominant disorder in
which excess protoporphyrins are produced. These protoporphyrins are detectable
in the blood and this forms the basis of diagnostic tests. Clinically, the disorder
often presents in childhood as episodes of skin soreness and extreme discomfort
when exposed to the sun. Swelling, redness and urticarial lesions may develop
in exposed skin. Later, ne, pitted scarring is found on exposed sites. Pigment
gallstones may develop.
ERYTHROPOIETIC PORPHYRIA (GUNTHERS DISEASE)

This is another very rare abnormality of porphyrin metabolism, inherited as an
autosomal recessive disorder. Affected individuals are extremely photosensitive
and shun the light. They develop dreadful facial scarring, with hirsutes. This combination of clinical features has suggested to some that these patients provoked the
fable of werewolves.
261
HAEMOCHROMATOSIS (BRONZED DIABETES)

There are primary and symptomatic forms of this disorder. In the primary form,
there is excessive gastrointestinal absorption of iron, resulting in iron deposition
in the liver, testes, skin and pancreas. Involvement of the skin causes a brown-grey
pigmentation due to both the iron and increased melanin in the skin. There is diabetes due to deposition of iron in the pancreas, and cirrhosis from liver involvement. The condition seems to be inherited as a recessive characteristic, but is much
more common in men.
Secondary forms are found in conditions necessitating repeated blood transfusion and in conditions in which there is chronic haemolysis (e.g. sickle cell disease).
AMYLOIDOSIS
Amyloidosis is the term used for a group of disorders in which an abnormal protein is deposited in tissues. Generalized amyloidosis is divided into primary and
secondary forms. The latter develops after long-standing inammatory disease,
including infections such as chronic tuberculosis and chronic osteomyelitis. It may
also occur in patients with long-standing severe rheumatoid arthritis. There are no
skin manifestations in secondary amyloidosis. In primary amyloidosis, the abnormal protein components are synthesized by clones of abnormal plasma cells and
the condition is sometimes associated with multiple myeloma. In primary amyloid
disease amyloid is deposited in various organs as well as in the skin. In the skin,
it is deposited in and around the dermal capillary blood vessels, which become
fragile and leaky. Swollen mauve-purple areas develop around the eyes and around
the exures.
There are also amyloid disorders that are restricted to the skin. In the rare macular amyloid, itchy, rippled, brown macular areas appear over the trunk (Fig. 17.3).
It seems to be more common in women and in patients of Asian origin. Histologically, the deposits of amyloid are detectable subepidermally. Lichen amyloidosis
is another rare cutaneous form of amyloid in which lichen planus-like lesions
occur.
Amyloid can be detected in tissue using various histochemical tests, including
birefringence with Congo red stain and uorescence with thioavine T, as well as
by immunocytochemical tests.
XANTHOMATA
Xanthomata are deposits of lipid in histiocytes in skin and may be associated
with normal levels of lipids in the blood (normolipaemia) or with elevated
levels of serum lipids (hyperlipidaemia). The lipidized histiocytes have a characteristic foamy appearance. The main hyperlipidaemic conditions are given in
Table 17.2.
262
Porphyrias
Figure 17.3 Pigmented

area on the back in
macular amyloid.
Table 17.2 The hyperlipidaemias (World Health Organization classication)

Type
Plasma
cholesterol
Plasma
triglycerides
Lipoproteins
elevated
Inheritance
Skin lesions
Systemic
manifestations
Chylomicrons
Autosomal
recessive
(BurgerGrtz
disease
Eruptive
xanthomata
Pancreatitis
Hepatosplenomegaly
Lipaemic retinalis
II
LDL
LDL, VLDL
Autosomal
dominant (familial
hypercholesteraemia)
Xanthelasma
Tendon/
tuberous
xanthoma
Corneal arcus
Accelerated
atherosclerosis
III
Chylomicron
Remnants LDL
Uncertain
Planar
xanthoma
Eruptive and
tendon
xanthoma
Accelerated
atherosclerosis
IV
VLDL
Uncertain
Eruptive
xanthoma
Accelerated
atherosclerosis
Glucose intolerance
Hyeruricaemia
VLDL
Chylomicrons
Uncertain
Eruptive
xanthoma
Pancreatis
Hepatosplenomegaly
Sensory neuropathy
Lipaemia retinalis
Hyperuricaemia
Glucose intolerance
LDL low density lipoproteins; VLDL very low density lipoproteins.
263
Figure 17.4 Yellowish plaques on the eyelids in

xanthelasma.
Figure 17.5 Xanthoma tuberosum affecting the knee.
Xanthelasma
Xanthelasma is a common form of xanthoma in which lesions appear as

arcuate or linear plaques around the eyes (Fig. 17.4). The condition is not associated with hyperlipidaemia in 6070 per cent of patients. The lesions can be
removed by excision or by topical treatment with trichloracetic acid if the
patient nds them a cosmetic nuisance. The latter can produce serious burns if it
is used incorrectly. The area around the lesion should be protected with Vaseline
and the surface of the lesion lightly wiped with a cotton-wool swab moistened
with the acid. In a few seconds, the treated area turns white and later a scale or
crust forms.
Xanthoma tuberosum
The lesions of xanthoma tuberosum are large nodules containing lipidized histiocytes and giant cells. The nodules develop around the tendons and extensor
aspects of the joints in familial hyperlipidaemia (see Table 17.2), particularly over
the Achilles tendon, the knees and elbows (Fig. 17.5).
Eruptive xanthomata
These mostly develop in diabetes, but are also seen in congenital deciencies
of lipoprotein lipase (BurgerGrtz disease: see Table 17.2). Large numbers of
yellowish-pink papules develop rapidly over the skin surface (Fig. 17.6).
Treatment
The treatment of these xanthomatous disorders is based on treatment of any

underlying disease, diet and the use of lipid-lowering agents.
264
Figure 17.6 Yellowish pink papules on the buttocks in

eruptive xanthoma.
Figure 17.7 Pathology of granuloma annulare

demonstrating a central necrobiotic area surrounded
by inammatory cells.
The term necrobiosis is applied to a particular histological change in which there
are foci of damage making the dermal structure blurred and more eosinophilic
than usual. The foci are surrounded by inammatory cells lymphocytes, histiocytes and occasional giant cells (Fig. 17.7)
GRANULOMA ANNULARE
This, not uncommon, inammatory disorder, often seen in children and young
adults, is characterized by papules and plaques that adopt a ring-like pattern
(Fig. 17.8). Lesions develop on the extensor aspects of the ngers, dorsa of the
feet, hands and wrists.
Granuloma annulare tends to last for a few months and then disappears as
mysteriously as it came. Treatment is generally not indicated.
A less common type, known as generalized supercial granuloma annulare,
is characterized by macular, dull-red or mauve areas rather than rings (Fig. 17.9),
which have a necrobiotic structure histologically. Diabetes is more common in
this group of patients.
Figure 17.8 A typical ring

of pale-pink papules in
granuloma annulare.
Case 17
Annie, aged 11, was brought to the surgery because of several pink plaques that had
developed in the previous 3 months on her ankles and the backs of the hands. The
plaques were static and did not trouble her. They were clinically typical of granuloma
annulare and this was conrmed by the nding of necrobiotic and granulomatous foci
histologically. They resolved without treatment after a further 6 months.
265
Figure 17.9 Flat, pink patches due to

diffuse granuloma annulare. This patient
also had diabetes.
NECROBIOSIS LIPOIDICA DIABETICORUM

This condition is seen in 0.3 per cent of diabetics and is strongly associated with the
diabetic state. It occurs mainly on the lower legs as yellowish-pink plaques, which
persist and become atrophic. It is characterized by necrobiotic foci histologically.

There is a group of poorly understood disorders that includes LettererSiwe disease
(LSD), HandSchllerChristian disease (HSCD), eosinophilic granuloma (EG),
xanthoma disseminatum (XD) and juvenile xanthogranuloma (JX). LSD, HSCD
and EG seem to belong to the same family of diseases, in which there appears to
be a reactive proliferation of Langerhans cells.
LSD is an uncommon disorder of infants and young children, characterized by
a papular and scaling eruption of exures, trunk and scalp, with some resemblance to seborrhoeic dermatitis. There is a dense inltrate of cells having the ultrastructural and immunocytochemical characteristics of Langerhans cells. There may
be severe malaise and hepatosplenomegaly and some patients succumb. Treatment
with corticosteroids and cytotoxic agents may be required.
In HSCD, abnormal Langerhans cell deposits occur mostly in the lung, pituitary, bone and orbit. In EG, the deposits are, for the most part, limited to the bony
skeleton.
266
Summary
XD and JX do not belong to the same Langerhans cell group of disorders,

but are characterized by the presence of lipidized histiocytes, giant cells and an
admixture of other cell types. In JX, isolated or limited numbers of yellowish-pink
nodules occur in young infants, which eventually disappear. In XD, many papular
lesions develop on the skin, and sometimes mucosae, which often persist for long
periods without serious consequences.
Summary
The porphyrias are disorders of haem molecule
metabolism. In porphyria cutanea tarda, there is a
defect in uroporphyrinogen decarboxylase, causing
uroporphyrins and copirorphyrins to accumulate in
the blood, stools and urine. PCT is associated
with liver disease; its genetic basis is uncertain.
Mauvish discoloration, blistering and hirsutes
occur in light-exposed sites.
Treatment is by regular venesection or by
administration of chloroquine, both of which
reduce levels of abnormal circulating porphyrins.
Porphyria variegata is a very rare, dominant
combination of PCT and acute intermittent
porphyria. Erythropoietic protoporphyria is another
rare, dominantly inherited disorder with
photosensitivity.
In primary haemochromatosis, there is excessive
gastrointestinal absorption of iron, with its
subsequent deposition in the viscera particularly
in the skin, causing pigmentation, and in the liver
and pancreas, causing cirrhosis and diabetes,
respectively. Secondary haemochromatosis occurs
as a result of chronic haemolysis or repeated
blood transfusion.
Amyloidosis describes a group of disorders in
which there is deposition of an abnormal protein.
Primary generalized amyloidosis is the result of an
abnormal clone of plasma cells and results in
amyloid deposition perivascularly in skin and
various organs. Secondary amyloidosis from
long-standing infection (e.g. tuberculosis) or

rheumatoid arthritis has no skin manifestations.
Macular amyloid causes rippled pigmentation of
the skin and is caused by subepidermal amyloid
deposits.
Xanthomata are deposits of lipid in histiocytes in
skin. In xanthelasma, lipid deposits occur around
the eyes without hyperlipidaemia in 70 per cent
of cases. In xanthoma tuberosum, nodular
deposits occur around tendons as a result
of familial hypercholesterolaemia. In eruptive
xanthoma, many small, pink-yellow papules
develop in the course of diabetes or BurgerGrtz
disease.
Granuloma annulare is a not uncommon,
self-limiting disorder, characterized by papules and
annular plaques in which there is a characteristic
histological picture of damaged connective tissue
(necrobiosis) and surrounding granulomatous
inammation. In necrobiosis lipoidica diabeticorum,
large, yellowish pink plaques occur preferentially
on the legs.
LettererSiwe disease is a sometimes fatal
disorder seen in infants and is marked by a
papular and scaling rash in the exures and scalp.
There is an inltrate of Langerhans cells in the skin
and viscera. Xanthoma disseminatum and juvenile
xanthogranuloma are in a different category and are
characterized by deposits of lipidized histiocytes
and other inammatory cells focally in skin.
267
C H A P T E R
18
Disorders of hair
and nails
Disorders of hair
268
276
Summary
279
Both hair and nails are epidermal structures that arise from invaginations of the
epidermis into the skin (Figs 18.1 and 18.2). Hair and nails may develop signs of
disorder such as psoriasis or lichen planus in the absence of obvious skin disease.
In addition, there are disorders that are conned to either the hair or the nails.
Disorders of hair
(Table 18.1)
HAIR LOSS (ALOPECIA)

Hair loss may be diffuse over the scalp or localized to one or several sites on
the scalp. The process may also be destructive and cause scarring or may be nonscarring in nature.
Congenital alopecia
Congenital alopecia may occur in isolation or with other congenital disorders.

Rarely, scalp hair growth is very slow and hair shaft density is low (congenital
hypotrichosis). A patch of scarring over the vertex with hair loss is another,
uncommon, type of congenital alopecia.
Pattern alopecia
Denition
This is a common, dominantly inherited, progressive form of alopecia, which is
mostly seen in men, develops symmetrically at certain specic sites on the scalp
and eventually causes almost complete scalp hair loss in some patients.
268
Disorders of hair
Hair shaft in hair

follicle canal
Epidermis
Sebaceous gland
Hair matrix
Hair papilla
(a)
(b)
(c)
Figure 18.1 (a) Diagram of a hair follicle showing the relationship between the hair
shaft, follicular epithelium and sebaceous glands. (b) Photomicrograph to show a hair
follicle on the scalp with arrectores pilorum muscles. (c) Photomicrograph to show a
hair follicle on the scalp with prominent hair matrix and hair papillae.
Nail plate
Nail matrix

show the nail plate and
the nail matrix tissue that
forms it.
269
Disorders of hair and nails
Table 18.1 Overview of hair disorders
Hair loss
(alopecia)
Non-scarring
Scarring
Increased hair growth (hirsutes)
Diffuse
Ageing
Telogen efuvium
Drug induced
Localized
Male pattern alopecia

areata
Mechanical causes
Trauma
Lupus erythematosus
Lichen planus
Constitutional
Androgenization
Drug induced
Clinical features
Loss of hair starts in both temporal regions. Shortly after this bitemporal recession,
thinning of the hair and then alopecia develop over the vertex. The bald area over the
vertex expands to meet the triangular temporal bald areas until, in the worst cases,
almost complete loss of hair results. A general reduction in the density of hair follicles
also occurs and this may be the main feature of the disorder in women, in whom
bitemporal recession and some vertical thinning occur less commonly than in men.
The condition may start as early as in the late teens, but generally declares its
presence in the third decade. Its rate of progress varies and seems uninuenced by
environmental factors.
Pattern alopecia causes an enormous amount of psychological distress and
patients will go to extraordinary lengths to attempt to arrest and reverse the
process and/or to disguise its presence. The condition is rmly embedded in popular mythology with regard to its supposed causes, which range from dietary
deciencies to sexual excesses.
The hair follicles in the affected areas become smaller and sparser and eventually
disappear. Finally, true atrophy of the skin occurs at the involved sites. The disorder is dominantly inherited, but requires androgenic stimulus in the form of
testosterone and the passing of the years for full phenotypic expression. The disorder can be precipitated by the administering of testosterone to female patients and
is also a sign of masculinization in patients with a testosterone-secreting tumour.
Treatment
There is no effective treatment. The progress of pattern alopecia in men may be
halted by castration, but there are few patients who would undergo the operation
for this purpose. In women, chemical castration with the use of an antiandrogenprostagen combination (cyproterone acetate and ethinylestranol
Dianette) has been tried and some reduction in the rate of hair loss claimed. The
270
Disorders of hair
antihypertensive vasodilator minoxidil has also been used topically, as increased

hair growth was noted as a side effect from its oral use. Although the drug may
increase hair growth in 2030 per cent of patients, the hair is lost again when
treatment stops, and the extent to which hair regrowth occurs is modest. More
recently, the drug nasteride has been used (this is a 5-alpha-reductase inhibitor)
in women, with good results claimed.
Case 18
Joan, aged 53, noticed that she was losing a lot of scalp hair. On examination, there
was some overall thinning, but the hair loss was more marked over the vertex and
at either temple. Joan remembered that her mother had also had some hair loss.
It was thought that she had pattern alopecia and she was put on treatment with
Dianette. After 6 months of treatment she thought the rate of hair loss was less.
Pattern hair loss in men may be disguised in a number of ways, including:
wigs and toupes and hair weaving, in which the remaining hair is woven to
cover the defect
surgical manoeuvres, in which plugs of hair-containing skin from the scalp
periphery are transplanted to holes made in the bald area or aps of skin are
advanced over bald areas.
Alopecia areata
Denition
Alopecia areata is an autoimmune disorder of hair follicles causing loss of hair in
sharply dened areas of skin.
Clinical features
Alopecia areata often starts quite suddenly as one or more rounded patches from
which the hair is lost (Fig. 18.3). The hair loss continues for days or weeks, until
Figure 18.3 Small,

discrete areas of hair
loss in alopecia areata.
271
Figure 18.4 Alopecia totalis: there is

loss of eyebrows too.
Figure 18.5 A large patch of alopecia areata showing

regrowth of non-pigmented hair.
all the hair from the affected sites has fallen. The individual areas vary in size from
1 cm2 to involvement of the entire scalp (alopecia totalis); rarely, the eyelashes and
eyebrows (Fig. 18.4) and all body hair are lost as well.
Affected areas may extend outwards and disease activity can be recognized by
the appearance of so-called exclamation mark hairs at the margin of the lesions.
The condition occurs over a wide age range, but seems particularly common
between the ages of 15 and 30 years.
Regrowth of alopecia areata patches occur in most patients if the affected areas
are small, limited in number, and the affected individual is 15 years old or less.
When regrowth occurs, the new hair is ne and non-pigmented (Fig. 18.5). The
outlook for regrowth worsens when large areas are affected, the patient is over
30 years old and also has atopic dermatitis.
The disorder is positively associated with autoimmune disorders, including
vitiligo and thyrotoxicosis, and it has been assumed that an immune attack is
launched against components of the hair follicle. When biopsies are taken from an
actively extending patch, a dense bee swarm-like cluster of lymphocytes can be
seen around the follicles.
Differential diagnosis
Patches of baldness due to hair pulling (trichotillomania) are bizarrely shaped,
not as well demarcated as alopecia areata, and have no exclamation mark hairs at
272
Disorders of hair
the edge. Tinea capitis is marked by broken hairs and by a degree of redness and
scaling of the scalp skin. Disorders that iname the skin and destroy hair follicles
can usually be easily differentiated by the scarring they cause.
Treatment
Patients with a solitary patch or few patches usually do not need treatment. When
the patches coalesce to become a problem cosmetically or when there is alopecia
totalis, treatment is often demanded by patients, but is not often effective. The following treatments have been used: potent topical steroids or systemic steroids;
photochemotherapy with long-wave ultraviolet irradiation (PUVA); dithranol;
allergic sensitization with diphencyprone; and topical minoxidil has been claimed
to be partially successful. All of the above have inconvenient side effects and usually work only while they are being given.
Allergic sensitization with 1 per cent diphencyprone causes an eczematous
response and kicks the follicles back to life in about half the patients and is quite
often used.
Many patients, having experienced the side effects and frustration of the lack
of efcacy of the treatments, decide to cut their losses and disguise their disability with a wig. Sympathy and support are the most useful applications for this
depressing disorder.
Diffuse hair loss
This is predominantly a problem for middle-aged and elderly women. It is not a

single entity and the causes include pattern alopecia, virilization, hypothyroidism,
systemic illness such as systemic lupus erythematosus, and drug administration
(particularly the anticancer drugs and the systemic retinoids). Diffuse hair loss is
also caused by telogen efuvium (see below). Ageing also results in a lesser density of hair follicles, which is more obvious in some subjects than in others.
Having considered the above possible causes, there are still some patients with
obvious diffuse hair loss for whom there is no adequate explanation. Various deciency states (particularly iron) have been incriminated, but in the majority of
instances the supposed deciency appears to have no other sequel and attempts at
its rectication fail to improve the clinical state.
If there is no obvious cause for diffuse hair loss, the only medical treatment
available is topical minoxidil, but this is unlikely to give substantial benet.
Telogen efuvium
The human hair cycle (Fig. 18.6) is asynchronous, but can be precipitated into
synchrony by childbirth or a sudden severe systemic illness such as pneumonia or
massive blood loss. The stimulus causes all the scalp hair follicles to revert to the
telogen, or resting, phase. There is a sudden and signicant loss of terminal scalp
hair some 3 months after the precipitating event, which continues for a few weeks
but then spontaneously stops. Hair regrowth gradually restores the scalp hair to
its original state.
273
Anagen
Catagen
Telogen
Remnant of i
root sheath
Sebaceo
duct
Outer root
sheath
Inner root
sheath
Early anagen
Outer root
sheath
Inner root
sheath
ub
Club
Sebaceous
gland
Telogen
lub hair
b
agen hair
Dermal papilla
Basal lamina
Dermal papilla
Dermal papilla
Dermal papilla
Figure 18.6 Diagram showing the various stages of the human hair cycle.
Traction alopecia
Repeated tugging and pulling on the hair shaft may produce loss of hair in the
affected areas, such as occurs when hair rollers are used (Fig. 18.7). It can also develop
in young children when they continually rub their scalp on their pillow. Youngsters
sometimes tug at their hair, producing the same effect in a bizarre distribution over
the scalp (trichitillomania, Fig. 18.8). The motivation for this strange behaviour usually remains obscure. The main differential diagnosis is alopecia areata.
Figure 18.7 Traction alopecia due to

the use of rollers.
Figure 18.8 Trichotillomania: a bizarre

pattern of hair loss from the scalp due
to constant tugging of the hair.
274
Disorders of hair
Scarring alopecia
Any inammatory process on the scalp sufcient to cause loss of follicles and scar
formation will result in permanent loss of hair in the affected area. Mechanical
trauma, burns, bacterial infections and severe inammatory ringworm of the
scalp can produce sufcient damage to cause scarring and permanent hair loss.
In discoid lupus erythematosus (see page 79) and lichen planus (see page 144),
the scalp skin may be characteristically affected by the dermatosis concerned, but
it may be difcult to distinguish these two conditions, even after biopsy. Usually,
the affected area is scarred and there is loss of follicular orices the few remaining being distorted and dilated and containing tufts of hair (Fig. 18.9). An odd and
unexplained type of scalp scarring known as pseudopelade is characterized by
small, rounded patches of scarring alopecia without any inammation.
Hair shaft disorders
Hair shaft abnormalities may be either congenital or acquired. Acquired abnormalities are more often seen. All long hairs tend to become weathered at their
ends due to climatic exposure and the usual washing and combing routines.
Twisting hairs between the ngers, and other obsessive manipulation of hair,
results in a specic type of damage to the hair shafts known as trichorrhexis
nodosa, in which expansions of the shaft (nodes) can be seen by routine light
microscopy and scanning electron microscopy. These nodes rupture and leave
frayed, paintbrush-like ends (Fig. 18.10). This deformity leads to broken hairs
and even to the complaint of loss of hair.
Figure 18.9 Scarring alopecia due to

discoid lupus erythematosus.
Figure 18.10 Scanning electron

micrograph of fractured hair shaft and
paintbrush-like end in trichorrhexis nodosa.
275
Figure 18.11 Hair shaft in monilethrix

showing alternate fusiform expansions
and thinning of the hair shaft in this
congenital disorder.
Isolated congenital hair shaft disorders include the condition of monilethrix,

in which there are spindle-like expansions of the hair shaft at regular intervals
(Fig. 18.11), causing weakness and breaking of the scalp hair.
HIRSUTES
Figure 18.12 Thimble

pitting of the ngernail in
psoriasis. There is also an
area of onycholysis.
This is the name given to the complaint of excessive hair growth in women. When
the hair growth is on the chin and upper lip, it causes considerable cosmetic
embarrassment, even though in most cases it is normal. When hair growth is
marked on the trunk and limbs, is accompanied by acne, early pattern alopecia
and menstrual irregularities, tests for masculinization and polycystic ovarian syndrome should be performed. Removal of facial hair is usually by depilatories, waxing or electrolysis.
Figure 18.13 Fingernail in

psoriasis showing marked
onycholysis and some
deformity of the nail plate.
Psoriasis, lichen planus and eczema may all affect the nails, causing characteristic
clinical appearances. Psoriasis characteristically causes thimble pitting of the ngernails (Fig. 18.12). It also causes well-dened pink/brown areas and onycholysis
(separation of the nail plate from the nail bed: Fig. 18.13). The toenails rarely
show these changes, but the nail plates may be thickened, with a yellowish brown
discoloration and subungual debris often making it difcult to distinguish from
ringworm of the nails. In lichen planus, the nail plate may develop longitudinal
ridging (Fig. 18.14), which, in the worst cases, may penetrate the whole nail.
The process may even destroy the nail matrix and cause permanent loss of the
nail. Eczema affecting the ngers may cause irregular deformities of the ngernails and even marked horizontal ridging.
276
Figure 18.14 Longitudinally ridged

ngernails in lichen planus.
Figure 18.15 Irregular, discoloured nail

plate seen in chronic paronychia.
PARONYCHIA
This term is applied to inammation of the tissues at the sides of the nail. In the
common form of chronic paronychia, the paronychial skin is thickened and reddened. It is often tender, and pus may be expressed from the space between the
nail fold and the nail plate. The eponychium disappears and the nail plate is often
discoloured and deformed (Fig. 18.15) and may demonstrate onycholysis (see
below). There is a deep recess between the nail fold and the nail plate, containing
debris and micro-organisms, which it is difcult to keep dry. The condition
mostly occurs in women whose occupation involves frequent hand washing or
other wet activities (e.g. cooks, cleaners, barmaids), and it seems likely that the
inability of this group of individuals to keep their hands dry contributes substantially to the conditions chronicity.
Candida micro-organisms may contribute to the recurrent inammation to
which the affected ngers are subject, but they are not the cause of the disorder.
The cause is compounded from mechanical trauma and over-hydration resulting
in microbial overgrowth in the nooks and crannies of the nail fold.
Treatment
The major goals in management are keeping the ngers completely dry and the
avoidance of manual work. Antimicrobial preparations in aqueous or alcoholic
vehicles are also useful (e.g. povidone-iodine or an imidazole lotion). Acute exacerbations may need to be treated with systemic antibiotics.
Providing the advice is taken and the treatment used, patients usually gradually improve.
ONYCHOLYSIS
Onycholysis is a physical sign in which the terminal nail plate separates from the
underlying nail bed. It is observed in psoriasis, eczema, chronic paronychia, the
yellow nail syndrome (see below), thyrotoxicosis, as a result of repeated mechanical trauma and for no known reason.
277
Case 19
Pauline, aged 30, worked in a mobile phone factory and noticed that she was
nding it difcult to pick up small articles from the bench because her nails
showed some separation from the nailbeds. The dermatologist told her that this
was called onycholysis and was due to her psoriasis.
BRITTLE NAILS AND ONYCHORRHEXIS

In older women, the nails may break easily and separate into horizontal strata
(onychorrhexis). Probably the single most important factor causing this problem
is repeated hydration and drying, as in housework, as well as mechanical and
chemical trauma.
THE NAILS IN SYSTEMIC DISEASE

Onycholysis due to thyrotoxicosis has already been mentioned. In hypoalbuminaemia (as in severe liver disease), the lunulae may be lost and the nail plate
turns a milky white. Beaus lines are horizontal ridges due to a sudden severe
illness, trauma and/or blood loss and presumably have the same signicance as
telogen efuvium. They grow outwards and are eventually lost.
BROWN-BLACK PIGMENTATION
Pigmented linear bands along the length of the nail may be due to a mole or, if of
recent onset, may be caused by a malignant melanoma. Brown-black areas may be
due to melanin or haemosiderin from trauma, and the two may be very difcult
to tell apart (Fig. 18.16). Uncommonly, Pseudomonas infection of the nail plate
produces a diffuse black or black-green pigmentation. A blackish, yellow-green
discoloration is also seen in the yellow nail syndrome (Fig. 18.17). In this rare disease, nail growth is greatly slowed and the nails are yellowish green, thickened and
show increased curvature. In addition, ankle and facial oedema, sinusitis and
pleural effusion often accompany this condition, which is of unknown cause.
RINGWORM OF THE NAILS (TINEA UNGUIUM)

Ringworm of the toenails is quite common, but much less common in the ngernails. The affected nails are thickened and crumbly and are discoloured yellow or
yellowish white or black (Fig. 18.18). Subungual debris is often present. The differential diagnosis includes psoriasis and paronychia as well as the rare yellow nail
syndrome.
Treatment
Figure 18.16 Subungual
haematoma.
Treatment is dealt with on page 315.
278
Summary
Figure 18.17 Nails in the yellow nail syndrome.

The nails are discoloured a yellowish green and show
increased curvature. There is also loss of eponychium.
(b)
(a)
Figure 18.18 (a) Deformity, discoloration and subungual debris in a big toenail due to ringworm infection (tinea
unguium). (b) Here, the second toe is also affected.
Summary
Hair loss may be non-scarring or scarring. Pattern
alopecia is a common, dominantly inherited,
progressive, non-scarring alopecia. Starting in the
temporal regions and on the vertex, it gradually
spreads, even involving the entire scalp. The
follicles become smaller in the affected area and
then disappear. Although it is heritable, the
androgenic stimulus of testosterone is needed for
expression of the disorder. There is no effective
treatment for men other than surgical transplant
techniques. In women, the anti-androgen
cyproterone acetate with ethinyl oestranol (Dianette)
has been used, as has the 5-alpha-reductase
inhibitor nasteride. Minoxidil (the antihypertensive)

has been used topically to stimulate hair growth,
but is only marginally effective.
In alopecia areata, hair follicle growth is arrested in
well-dened areas of variable size due to an
autoimmune process. Regrowth usually occurs in
young patients, but when the condition is extensive,
affecting eyebrows and body hair, it may persist.
Solitary or a few small patches usually do not
require treatment. When extensive, topical or even
systemic steroids or allergic sensitization with
1 per cent diphencyprone causing an eczema
stimulates hair growth in a proportion of cases.
279
Diffuse hair loss in mature and elderly women is

caused by hypothyroidism, systemic illness, telogen
efuvium and ageing, but is unexplained in many
cases.
Telogen efuvium is caused by sudden
synchronization of many hair follicles so that they
revert to the telogen phase because of sudden
illness or blood loss. Hair loss occurs some
3 months after the event and the hair then regrows.
Hair loss occurs focally due to hair pulling
(trichitillomania) or other form of pulling
(e.g. from rollers).
Alopecia due to scarring occurs after trauma,
infection or diseases such as discoid lupus
erythematosus and lichen planus.
Hair shaft abnormalities leading to broken hairs
occur in trichorrhexis nodosa, characterized by
nodular swellings along the hair shaft due to
twisting and manipulation, and the congenital

disorder monilethrix, in which fusiform swellings
occur along the hair shaft.
Pitting of the nail plate is commonly observed in
psoriasis, with separation of the distal nail plate
from the nail bed (onycholysis) and discolorations.
Ridging and irregularities are observed in other
inammatory skin disorders.
Paronychia is inammation of the tissues at the
side of the nail plate. The chronic form causes
recurrent inammation of the paronychial tissues
and is due to trauma and maceration of the
tissues between the nail plate and the skin.
The most important part of the treatment is to
keep the nail dry.
Nails affected by ringworm (tinea unguium) are
thickened and crumbly and discoloured yellowish
white or brown-black.
280
C H A P T E R
19
Systemic disease
and the skin
281
285
288
289
291
292
Hepatic disease
292
293
Summary
293

Some skin disorders are precipitated by an underlying malignancy and others
almost always indicate a visceral neoplasm. Early recognition may assist detection
of the underlying neoplastic disease (Table 19.1).
DISORDERS WITH A STRONG ASSOCIATION WITH

UNDERLYING MALIGNANCY
Necrolytic migratory erythema
This is usually caused by a tumour of the pancreatic islet alpha cells that secrete
glucagon, but it is sometimes caused by hyperplasia or benign adenomatosis of
these cells. Rarely, no underlying abnormality can be found. Areas of erythema,
which become eroded and crusted (Fig. 19.1), develop around the groins, on the
lower trunk, around the exures and at the sides of the mouth. They may temporarily remit at one site, to appear elsewhere. The skin disorder responds to
removal of the underlying tumour, but usually complete removal is not possible.
281
Systemic disease and the skin
Table 19.1 Skin markers of malignant disease

Disorder
Comment
Acquired ichthyosis
Distinguish from the mild xerosis caused by reticulosis,

lipid lowering drugs, leprosy and AIDS
Acanthosis nigricans
Distinguish from pseudo-acanthosis nigricans; mostly

associated with gastrointestinal adenocarcinoma
Dermatomyositis
Associated with several neoplastic diseases, but

particularly of the genital system in women over 40
Erythema gyratum repens Very rare; strong association with underlying carcinoma
Necrolytic migratory
erythema
Strong association with pancreatic alpha-cell tumour;

diabetes and low plasma amino acids accompany
Bullous pemphigoid
May be weak association with malignancy, but not certain
Skin metastases
6 per cent of all metastases; metastases from

carcinomas of lung, prostate, breast, kidney and
stomach
Figure 19.1 Necrolytic migratory erythema: an area of

erythema and erosion on the forearm.
Figure 19.2 Pathology of necrolytic migratory erythema

showing degenerative change in the upper epidermis
with crusting and parakeratosis.
Characteristically, there is degenerative change in the upper epidermis

(Fig. 19.2). Blood tests reveal increased circulating glucagon, hyperglycaemia and
hypoaminoacidaemia and it is the last of these that may be responsible for this
curious skin disorder.
282
Figure 19.3 Acanthosis nigricans: increased

pigmentation and rugosity with skin tags in the axilla.
Figure 19.4 Acanthosis nigricans: increased

pigmentation, rugosity and skin tags around the neck.
Acanthosis nigricans
Acanthosis nigricans may occur in association with endocrine disease and also,
rarely, accompanies lipodystrophies. An identical clinical picture accompanies obesity and is then known as pseudoacanthosis nigricans. When the condition occurs in
an adult unaccompanied by obesity or endocrine disease, an underlying neoplasm is
usually the cause. The neoplasm involved is often a gastrointestinal adenocarcinoma.
There is a velvety thickening and increased rugosity of the skin of the exures
the axillae and groins in particular (Fig. 19.3). The sides and back of the neck and
the sides of the mouth are also affected.
The thickened areas are also pigmented and bear skin tags and seborrhoeic warts
(Fig. 19.4). There may also be some generalized increase in pigmentation, as well as
thickening and increased rugosity of the buccal mucosa and the palmar skin.
There is overall hypertrophy of all components of the skin of the affected areas.
Insulin-like growth factors may be involved.
Erythema gyratum repens
This is probably the rarest of the specic skin markers of visceral malignancy. This
odd disorder is almost always a marker of a neoplasm, often carcinoma of the
bronchus.
Large rings composed of reddened polycyclic bands are seen; the rings contain
concentric rings, giving a wood-grain effect (Fig. 19.5). The rings gradually
enlarge and change shape. Rarely, other less dramatic types of annular erythema
may be signs of an internal malignancy.
283
Figure 19.5 Erythema gyratum repens in a patient

with carcinoma of the lung. Note the concentric areas
of scaling.
Figure 19.6 Numerous small metastases from carcinoma

of the vulva.
Skin metastases
Carcinomas of the breast, bronchus, stomach, kidney and prostate are the most
common visceral neoplasms to metastasize to the skin. Secondary deposits on the
skin may be the rst sign of the underlying visceral cancer. The lesions themselves
are usually smooth nodules, which are pink or skin coloured (Fig. 19.6), but may
be pigmented in deposits of melanoma.
Acquired ichthyosis
When generalized scaling without erythema begins in adult life, it is quite likely
that there is an underlying neoplasm, particularly a reticulosis. This has to be distinguished from mild dryness of the skin and the slight irritation seen in many
chronic disorders, known as xeroderma.
Other causes of acquired ichthyosis include acquired immune deciency syndrome (AIDS), sarcoidosis and leprosy, but if these can be excluded, a neoplastic
cause is the most likely explanation (Fig. 19.7).
DISORDERS THAT ARE SOMETIMES ASSOCIATED WITH

UNDERLYING MALIGNANT DISEASE
Bullous pemphigoid
This subepidermal blistering disorder occurs mainly in those over 60 years of age,
who are anyway more likely to be affected by a neoplasm. Nonetheless, there are a
few patients with pemphigoid in whom the skin disorder is provoked by the
malignancy and remits after the neoplasm has been removed.
Dermatomyositis
Women over the age of 40 years with dermatomyositis may have 50 per cent
chance of a malignant tumour of the genitourinary tract, but infants with the
284
Figure 19.7 This woman suddenly developed dry and

itchy skin. On investigation, she was found to have
Hodgkins disease.
Figure 19.8 Plaque of pretibial myxoedema.
disease have no greater risk than a control group. Overall, even in adults, the association is not common and most cases of dermatomyositis occur without an identiable cause. There is an impression that dermatomyositis provoked by malignant
disease is more severe.
Figurate erythemas
Rarely, annular erythema and erythema multiforme (see page 75) seem to be
caused by underlying malignant disease.

THYROID DISEASE
Pretibial myxoedema is characterized by reddened, elevated plaques, often with a
peau dorange appearance on the surface (Fig. 19.8). Histologically, there is a cellular connective tissue with deposition of mucinous material. The serum from such
patients contains substances that stimulate the growth and activity of broblasts.
The condition is almost always a sign of thyrotoxicosis and is accompanied by
exophthalmos. It occurs in 5 per cent of patients with thyrotoxicosis. It is persistent
and difcult to treat, although treatment with PUVA is sometimes successful.
Rarely, there is diffuse inltration with similar mucinous connective tissue of the
hands and feet and nger clubbing in the condition of thyroid acropachy. Patients
with thyrotoxicosis have warm, sweaty skin and a proportion complain of pruritus.
In myxoedema, the skin often feels dry and rough and may have a yellowish
orange tint, as carotenaemia may accompany the disorder. In addition, there may
285
be coarsening of the scalp hair, hair loss, loss of the outer third of the eyebrows,
pinkish cheeks but a yellowish background colour the so-called peaches and
cream complexion.
SKIN MANIFESTATION OF DIABETES

Necrobiosis lipoidica
The skin manifestations of diabetes are summarized in Table 19.2. The most specic is necrobiosis lipoidica. More than 50 per cent of individuals who present
with this disorder will already have insulin-dependent diabetes. Many of those
who do not have diabetes when they present will develop diabetes or have a rstdegree relative with diabetes.
Typically, irregular yellowish pink plaques occur on the lower legs and around
the ankles (Fig. 19.9). Uncommonly, lesions may occur elsewhere and there may be
areas of atrophy and ulceration. These plaques are persistent and quite resistant to
treatment.
Histologically, there is a central area of altered and damaged collagen in the
mid-dermis, surrounded by inammatory cells, including giant cells.
Case 20
Julie, aged 19, reported to her GP that she was micturating much more often than
usual and was also feeling abnormally thirsty. When she was examined, the
doctor found an elevated, irregular, yellowish pink patch measuring 2.5 by 4.0 cm
on her left shin. There was also a smaller, similar patch on her right lower leg.
These patches had been present for 6 months. They had originally enlarged in
size, but were now static. It was thought that Julie had diabetes and that the leg
patches were due to necrobiosis lipoidica diabeticorum. It was explained to her
that, unfortunately, there was no certain cure for the disorder.
Table 19.2 Skin manifestations of diabetes

Skin manifestation
Comment
Necrobiosis lipoidica
Majority of patients with this disorder eventually

have diabetes
Diffuse granuloma annulare
Rare type of granuloma annulare with strong

association with diabetes
Xanthomas
Eruptive xanthomata seen in uncontrolled diabetes
Neuropathic ulceration
Due to neuropathy; perforating ulcers may occur on

sole of foot
Ischaemic changes
and infection
Increased incidence and severity of atherosclerosis

and microvascular disease may lead to ischaemic
necrosis and increased incidence of skin infection
286
Figure 19.9 Necrobiosis lipoidica on

the ankle.
Figure 19.10 Perforating ulcer on the

sole of a patient with diabetes.
Granuloma annulare
This disorder has some supercial resemblance to necrobiosis lipoidica, both clinically and histologically, but in its common form has no association with diabetes.
However, there is a rare, generalized and diffuse form that is strongly related to
diabetes.
Ulceration of the skin in diabetes
The neuropathy of diabetes can result in neuropathic ulceration due to failure of

the so-called nociceptive reex, in which the limb is rapidly withdrawn from a
painful stimulus. Deep perforating ulcers may develop on the soles and elsewhere
around the feet (Fig. 19.10).
Atherosclerotic vascular disease is more common in diabetics and the resulting
ischaemia may also contribute substantially to the ulceration of the feet or legs.
There is also a depressed ability to cope with infections, and infection of the ulcerated area usually complicates such lesions in diabetics. The resulting ulcerating areas
tend to be moist, contain slough and be purulent. Wounds in diabetics also tend to
heal more slowly, turning any minor injury of the foot into a serious health risk.
Xanthomata
Xanthomata are due to deposits of lipid within dermal histiocytes. Their clinical
appearance and lipid composition depend on the type of lipid abnormality.
287
Figure 19.11 Numerous

yellow-pink papules due
to eruptive xanthoma in a
patient with diabetes.
In diabetes, there is usually a mixed hyperlipidaemia in which both cholesterol

and triglycerides are elevated. When the lipid levels are very elevated, eruptive
xanthomata may develop in which numerous, small, yellow-pink papules appear
anywhere, but especially on extensor surfaces (Fig. 19.11).

As mentioned above, diabetics appear particularly susceptible to skin infections.
Monilial infection is a particular problem and monilial vulvovaginitis and balanoposthitis are common. These are itchy disorders and it may be that this is how
it came to be believed that diabetics can develop generalized itch. In fact, there is
little evidence that diabetes is responsible for generalized itch.
CUSHINGS SYNDROME
The cutaneous signs of Cushings syndrome are the same regardless of whether
they are caused by an adrenal tumour, hyperplasia or the administration of
corticoids.
Clinical features
Figure 19.12 Skin thinning

in Cushings syndrome.
The most consistent clinical feature is skin thinning. The underlying veins can
be easily seen and the skin has a transparent quality (Fig. 19.12). The thinning
is due to the suppressive action of glucocorticoids on the growth and synthetic
activity of dermal broblasts and the epidermis.
The dermal thinning also results in rupture of the elastic bres and striae distensae (Fig. 19.13). These are band-like atrophic areas that develop in areas of
maximal stress on the skin. A certain number are found on the upper arm, the
anterior axillary fold, the lower back and occasionally elsewhere in normal
adolescents. They also occur in most pregnant women on the thighs, breasts,
288
Figure 19.13 Striae distensae of the anterior axillary

fold in iatrogenic Cushings syndrome.
Figure 19.14 Hyperpigmentation of facial skin in Addisons

syndrome.
anterior axillary folds and lower abdomen. It is thought that both tissue tension and the level of circulating glucocorticoids are important in the production of striae.
Acne papules occur on the chest, back and face in most patients with Cushings
syndrome. Steroid acne lesions are more uniform in appearance than adolescent acne and consist predominantly of small papules with few comedones.
This type of acne is more resistant to treatment than ordinary acne.
Skin infections are also more common and more severe in patients with Cushings
syndrome. Pityriasis versicolor is often present and often very extensive.
ADDISONS DISEASE
This disorder, due to destruction of the adrenal cortex from autoimmune inuences, tuberculosis and amyloidosis of metastatic neoplastic disease, results in
weakness, hypotension and generalized hyperpigmentation (Fig. 19.14). The
increased pigmentation may be particularly evident on the buccal mucosa and in
the palmar creases.
This disorder of women is due to androgen-secreting tumours of the ovaries or
the adrenal cortex, but is usually due to polycystic ovaries in which there is an
289
Figure 19.15 Hirsutes due to

androgenization.
abnormality of steroid metabolism leading to an accumulation of androgens.

Patients present with acne and increased greasiness of the skin.
Increased hair growth is also a major complaint of patients with androgenization. Vellus hair on forearms, thighs and trunk is transformed to pigmented, thick,
terminal hairs. A masculine distribution of body and limb hair develops.
The appearance of beard hair is usually the reason for patients attending the
clinic (Fig. 19.15). In clinical practice, the most common problem is to distinguish
hirsutes due to androgenization from hirsutes due to non-endocrine causes. It is
not generally recognized that the presence of some terminal hair on the face
or limbs of some otherwise healthy women is normal. This is particularly
the case in dark-complexioned women of Arab, Asian or Mediterranean descent.
The tendency for excess hair is also familial. Thinning of the scalp hair and
pattern alopecia are also quite common and very distressing to women with
virilization.
In authentic virilization, the following features help distinguish the condition
from non-endrocrine hirsutes:
the excess hair is recent in onset and progressively becoming more noticeable
the hirsutes is accompanied by other physical signs including acne and
seborrhoea
there is signicant menstrual disturbance.
In most cases, extensive investigation is not appropriate and plasma testosterone

and abdominal ultrasound are all that are required.
290

VITAMIN A (RETINOL)
Retinol is a vital, lipid-soluble vitamin found in dairy produce and liver and is also
obtainable in the form of beta-carotene from carrots, tomatoes and other vegetables. It is essential for growth and development, resistance to infection, reproduction and visual function. In deciency states, it causes follicular hyperkeratosis
and roughening of the skin (phrynoderma). When excessive amounts are
ingested, pruritus, widespread erythema and peeling of the palms and soles occur.
These symptoms and signs are similar to those of retinoid toxicity.
NICOTINIC ACID
This is a water-soluble B vitamin found in grains and vegetables. Deciency
causes the condition of pellagra, resulting in diarrhoea, dementia and a photosensitivity dermatitis. The photosensitivity dermatitis develops a characteristic post-inammatory hyperpigmentation and is often very marked around
the neck.
VITAMIN C (ASCORBIC ACID)

Vitamin C is a water-soluble vitamin found in fruit and vegetables. Deciency
results in scurvy, which causes a clotting defect and poor wound healing. A characteristic rash seen in patients with scurvy consists of numerous tiny haemorrhages around hair follicles.
KWASHIORKOR
This is due to severe protein deciency in children and is seen in the poorer,
underprivileged parts of the world, including areas of Africa and India.
Generalized oedema develops and the degree of skin pigmentation decreases. In
addition, the hair becomes reddish during the time of the deciency the socalled ag sign.
SENILE OSTEOPOROSIS
In this disorder of faulty bone mineralization due to vitamin D deciency, bone
thinning and multiple fractures, the skin becomes thinner and is almost transparent, with the veins being abnormally prominent (Fig. 19.16). The thinning can
be demonstrated by ultrasound.
291
Figure 19.16 Thin,

fragile skin of the back of
the hand due to
osteoporosis.

There are numerous interrelationships between the skin and the gastrointestinal
tract, and only the more important ones fall within the scope of a book of this size.
DERMATITIS HERPETIFORMIS
This itchy, blistering disorder is strongly associated with an absorptive defect of
the small bowel. Small-bowel mucosal biopsy demonstrates partial villous atrophy
in some 7080 per cent of patients with dermatitis herpetiformis. There are also
some minor functional absorptive abnormalities in most patients. This gut disorder is, in fact, a form of gluten enteropathy (as is coeliac disease) and can be
improved by a gluten-free diet.
PEUTZJEGHERS SYNDROME
This is a rare, autosomal dominant disorder in which perioral and labial pigmented macules occur in association with jejunal polyps. Pigmented macules also
occur over the ngers.
GARDENERS SYNDROME
In this dominant disorder, epidermoid cysts and benign epidermal tumours occur
in association with colonic polyposis.
Hepatic disease
In severe chronic hepatocellular liver failure, hypoalbuminaemia occurs, which
results in the curious sign of whitening of the ngernails (Fig. 19.17). Severe liver
292
Summary
Figure 19.17 White ngernails due to

liver disease.
failure may also cause multiple spider naevi to develop over the arms, upper trunk
and face. These vascular anomalies consist of a central feeding blood vessel (the
body) with numerous ne radiating legs. Their cause is uncertain, but they may
be related to the plasma levels of unconjugated oestrogens.
In biliary cirrhosis, severe pruritus develops, resulting in excoriations and prurigo
papules. Jaundice and a generalized dusky pigmentation are seen in addition.
End-stage renal failure (uraemia) often causes persistent severe itch. The itch is
accompanied by a dusky, grey-brown pigmentation.
Obstructive jaundice from any cause results in intolerable itching.
Thyrotoxicosis sometimes causes itching, but does not seem to be due to the
sweatiness or increased warmth of the skin experienced by such patients.
Itching is sometimes a complaint of patients with hyperparathyroidism.
The symptom of itch is occasionally a sign of Hodgkins disease or, less often,
of another type of lymphoma. Rarely, the itch is a presenting symptom of the
neoplasm.
Itch is a well-known disabling complaint of patients with polycythaemia rubra
vera. For some curious reason, the itch may be a particular problem when these
patients have a bath.
It has often been claimed that patients with diabetes have pruritus, but if this
is the case, it must be extremely rare. Diabetics are prone to candidiasis, which
causes perigenital itch, and it is possible that this is how the idea began.
Summary
Certain skin disorders are precipitated by an
underlying malignancy. These include acanthosis
nigricans, erythema gyratum repens, acquired
ichthyosis and necrolytic migratory erythema.
Necrolytic migratory erythema is a persistent,

erosive, migratory rash associated with excess
glucagon secretion from a pancreatic alpha cell
tumour or hyperplasia.
293
Acanthosis nigricans causes velvety thickening in

the exures, a generalized increase in pigmentation
and an increase in skin tags and seborrhoeic warts.
It is mainly seen in gastrointestinal malignancies,
but also occurs in some endocrine disorders
and obesity.
Acquired ichthyosis occurs in lymphoma, but also in
AIDS and leprosy.
Dermatomyositis, bullous pemphigoid and the
gurate erythemas are associated with malignant
disease in some patients. Erythema gyratum repens
is an odd erythematous rash with a wood-grain
pattern, which is specically associated with
visceral malignancy.
In pretibial myxoedema, there are reddened plaques
on the lower legs. It is seen in 5 per cent of
thyrotoxic patients and is accompanied by
exophthalmos.
Necrobiosis lipoidica is strongly associated with
diabetes. In this condition, persistent, irregular,
yellowish plaques occur on the lower legs.
Histologically, granulomatous inammation
surrounds areas of collagenous degeneration.
Eruptive xanthomata (due to mixed hyperlipidaemia),
ulceration (due to neuropathy causing perforating
ulcers or due to ischaemia and infection) and
generalized diffuse granuloma annulare are also

associated with diabetes.
Skin thinning, striae distensae, acne and
susceptibility to skin infection are features of
Cushings syndrome and due to increased secretion
of glucocorticoids from the adrenal cortex.
Generalized hyperpigmentation is also a feature of
Addisons disease, caused by destruction of the
adrenal cortex.
Polycystic ovaries or ovarian tumours cause
androgenization (virilization), with increased limb
and facial hair, seborrhoea and acne.
The skin manifestations of vitamin deciency include
phrynoderma in retinol deciency, pellagra in nicotinic
acid deciency and scurvy in ascorbic acid deciency.
Dermatitis herpetiformis is an autoimmune, itchy,
blistering disease in which 70 per cent of patients
show jejunal partial villous atrophy and a minor
degree of malabsorption.
White ngernails due to hypoalbuminaemia and
multiple spider naevi are characteristic of severe
liver disease.
Generalized pruritus is a feature of renal failure,
obstructive jaundice (especially biliary cirrhosis),
thyrotoxicosis, lymphoma, polycythaemia rubra
vera and hyperparathyroidism.
294
C H A P T E R
20
Disorders of
pigmentation
296
297
Hyperpigmentation
299
Summary
302
Melanin pigment is produced in melanocytes in the basal layer of the epidermis.

The degree of racial pigmentation does not depend on the number of melanocytes present, but on their metabolic activity and the size and shape of their
melanin-producing organelles the melanosomes. Melanocytes account for
510 per cent of the cells in the basal layer of the epidermis. They are dendritic
(Fig. 20.1), but appear as clear cells in formalin-xed sections (Fig. 20.2).
Melanin synthesis is controlled by melanocyte-stimulating hormone and is
inuenced by oestrogens and androgens. Melanocytes are also stimulated by ultraviolet radiation (UVR) and by other irritative stimuli.
Figure 20.1 Dihydroxyphenylalanine (DOPA) oxidase

reaction to reveal melanocytes in the basal layer of the
epidermis as blackened cells with dendritic processes.
Figure 20.2 Formalin-xed histological section of

normal skin showing several clear cells at the base
representing melanocytes.
295
Disorders of pigmentation
Dendrites
Nucleus
Nucleolus
Developing melanosomes
stages IIV
Figure 20.3 Diagram

of a melanocyte showing
dendrites and different
stages of melanosomes.
Melanin is a complex, black-brown polymer synthesized from the amino acid

dihydroxyphenylalanine (L-DOPA; Fig. 20.3). Two forms of melanin exist: ordinary melanin, known as eumelanin, and a reddish melanin synthesized from
cysteinyl DOPA, known as phaeomelanin.
Melanin synthesis is initially catalysed by a copper-containing enzyme known
as tyrosinase, which also catalyses the transformation of L-DOPA to tyrosine.
Melanin is produced in melanocytes, but donated via their dendrites to neighbouring keratinocytes. The melanin granules then ascend through the epidermis
in the keratinocytes. Melanosomes go through several stages of melanin synthesis
during their melaninization (stages IIV). Mature melanosomes aggregate into
melanin granules and it is these granular particles within keratinocytes that give
protection against damage from UVR.
Melanin in keratinocytes is black and absorbs all visible light, UVR and
infrared radiation. It is also a powerful electron acceptor and may have other
uncharacterized protective functions.
Excessive pigmentation is known as hyperpigmentation, and decreased pigmentation is known as hypopigmentation. Both may be localized or generalized.
Non-melanin pigments may also cause skin darkening.
OCULOCUTANEOUS ALBINISM
There are several varieties of genetically determined defects in melanin synthesis,
the most common of which is recessively inherited oculocutaneous albinism.
Affected individuals have a very pale or even pinkish complexion with axen,
white or slightly yellowish hair and very light-blue or even pink eyes. Albinos are
also subject to nystagmus, either horizontal or rotatory. In addition, they are photophobic and often have serious refractive errors. They are extremely sensitive to the
harmful effects of solar irradiation and in sunny climates often develop skin cancers.
296
Albinos have a normal number of melanocytes in the basal layer of the epidermis, but lack tyrosinase and are unable to synthesize melanin. If hair is plucked and
incubated in a medium containing L-DOPA, the hair bulb does not turn black, as
it does normally.
Management
Albino patients must learn to protect themselves against UVR with sunscreens
and avoidance of sun wherever possible. Regular checking to detect early changes
of skin cancer is also important.
OTHER FORMS OF ALBINISM

There are several other types of albinism, most of which are recessive. In
HermanskiPudlak syndrome, there is an associated clotting defect due to a platelet abnormality. This is tyrosinase positive and hair bulbs turn black after they are
incubated with L-DOPA.
In several types of albinism, the abnormality of melanin synthesis is conned
to the eyes.
PIEBALDISM
In this condition, there is a white forelock and white patches on the skin surface.
In Waardenburgs syndrome, the condition is associated with sensory deafness.
VITILIGO
Denition
This is a common skin disorder in which there is focal failure of pigmentation due
to destruction of melanocytes that is thought to be mediated by immunological
mechanisms.
Clinical features
Sharply dened areas of depigmentation appear (Fig. 20.4). The depigmented

patches are often symmetrical, especially when they are over the limbs and face.
Odd patterns sometimes occur, as when depigmented patches develop over the
location of endocrine glands.
It is more noticeable in summer when the surrounding skin is sunburnt. It is
a serious cosmetic problem for darkly pigmented people.
The condition often starts in childhood and either spreads, ultimately causing
total depigmentation, or persists, with irregular remissions and relapses.
297
(a)
(b)
Figure 20.4 (a) A sharply dened patch of vitiligo on the neck. (b) Vitiligo in a
dark-skinned patient.
In halo naevus (Suttons naevus), the depigmentation of vitiligo begins around

one or a few compound naevi.
Pathogenesis and epidemiology
Vitiligo occurs in 12 per cent of the population and is more common when it
has occurred in other members of the family. It is also more common in diabetes,
thyroid disease and alopecia areata, and appears to be due to an autoimmune
attack on melanocytes.
Treatment
Treatments with topical corticosteroids or photochemotherapy with long-wave

ultraviolet irradiation (PUVA) are sometimes effective in stimulating repigmentation, but the response is irregular. Reassurance and cosmetic camouage are
sufcient for most patients.
Case 21
Mohammed was aged 23 when he rst developed a sharply dened, white area
on his face. Over the following months, the patch enlarged and others appeared.
His uncle had had vitiligo. Treatment for Mohammeds vitiligo did not seem to
help a great deal, but, after several years, some of the patches repigmented
spontaneously.
298
Hyperpigmentation
Table 20.1 Causes of localized hypopigmentation

Disorder
Comment
Vitiligo
Destruction of melanocytes; common; acquired; multiple,

sharply dened, non-pigmented patches anywhere
Pityriasis versicolor
Supercial yeast infection (Malassezia furfur) leading to

disturbance in pigment production; common; multiple,
pale, scaling patches on trunk
Pityriasis alba
Mild, patchy eczema of the face in children causing a

disturbance in pigment production
Leprosy
One or several paler macules on trunk or limbs that are

hypoaesthetic
White macules of
tuberous sclerosis
Uncommon developmental anomaly affecting central

nervous system, connective tissue and skin; several
maple leaf-shaped, hypopigmented macules
Naevus anaemicus
Rare, developmental, solitary white patch, usually on

trunk; thought to have a vascular basis
Chemical toxicity
May look like vitiligo; seen in workers in the rubber

industry exposed to paratertiary benzyltoluene
OTHER CAUSES OF LOCALIZED DEPIGMENTATION OF SKIN

In many countries, the fear of leprosy makes the differential diagnosis of a white
patch an urgent and vitally important issue. The causes are summarized in
Table 20.1. Examination in long-wave UVR distinguishes total depigmentation (as
in vitiligo) and helps identify areas of depigmentation. It also detects the yellowgreen uorescence in some cases of pityriasis versicolor.
Hyperpigmentation
It has to be determined whether the pigmentation is due to melanin or some other
pigment (Table 20.2).
Generalized melanin hyperpigmentation is seen in Addisons disease due to
destruction of the adrenal cortex from tuberculosis, autoimmune inuences, metastases or amyloidosis. Pigmentation is marked in the exures and exposed areas, but
the mucosae and nails are also hyperpigmented. The diagnosis is supported by
hypotension, hyponatraemia and extreme weakness. The hyperpigmentation is due
to an excess of pituitary peptides resulting from the lack of adrenal steroids. After
bilateral adrenalectomy, pigmentation may be extreme (Nelsons syndrome).
Generalized hyperpigmentation may be part of acanthosis nigricans (see
page 283), which is much more marked in the exures and is accompanied by
exaggerated skin markings and skin tags.
299
Table 20.2 Non-melanin causes of brown-black discoloration

Haemosiderin from broken haem pigment in extravasated blood
Homogentisic acid deposited in cartilage, in particular, in the inherited metabolic
defect known as alkaptonuria
Unknown pigment in thickened stratum corneum of severe disorders of
keratinization such as lamellar ichthyosis
Drugs and heavy-metal toxicity: dark pigmentation of skin and mucosae seen in
silver, gold, mercury and arsenic poisoning; amiodarone and phenothiazines cause
slate-grey, dusky skin pigmentation in exposed sites; minocycline may cause
patchy pigmentation in exposed or other sites
A bronzed appearance is seen in primary haemochromatosis (bronzed diabetes), in which iron is deposited in the viscera, including the pancreas (giving
rise to diabetes) and the liver (causing cirrhosis). The increased pigmentation is
caused by both iron and excess melaninization in the skin. Increased pigment is
also evident in secondary haemosiderosis. Generalized hyperpigmentation is also
seen in cirrhosis, particularly biliary cirrhosis, chronic renal failure, glycogen storage disease and Gauchers disease. Biliary cirrhosis and renal failure are usually
accompanied by severe pruritus.
Drugs can cause generalized diffuse hyperpigmentation, patchy generalized
or localized hyperpigmentation. Classic examples are due to the rare heavy metal
intoxications. Arsenic ingestion causes a generalized raindrop pattern of hyperpigmentation, and topical silver preparations cause argyria, producing a dusky,
greyish discoloration of the skin and mucosae.
Modern drugs can also produce darkening. Minoxycycline (Minocin) can
cause darkening of the scars of acne; it can also produce dark patches on exposed
areas. The pigment is a complex of iron, the drug and melanin and the condition
is only partially reversible. Amiodarone, the antiarrhythmic drug, causes a characteristic greyish colour on exposed sites. The phenothiazines, in high doses over
long periods, produce a purplish discoloration in the exposed areas due to the
deposition of a drugmelanin complex in the skin. Chlorpromazine is particularly
prone to doing this.
Carotenaemia produces an orange-yellow, golden hue due to the deposition
of beta-carotene in the skin. It is seen in food faddists who eat large amounts of
carrots and other red vegetables. Beta-carotene is also given for the condition of
erythropoietic protoporphyria (see page 261).
Canthexanthin is another carotenoid that produces a similar skin colour and
was sold for this purpose to simulate a bronzed suntan. Pigment crystals were
found in the retina of patients taking the drug and it has been withdrawn for this
reason.
Transient skin discoloration is seen in methaemoglobinaemia and sulphaemoglobinaemia due to dapsone administration.
300
Hyperpigmentation
Figure 20.5 Macular grey-brown

pigmentation in naevus of Ota.
Figure 20.6 Light-brown macule (caf au lait) due to Von

Recklinghausens disease.
LOCALIZED HYPERPIGMENTATION
Mongolian spots, the naevus of Ota and the naevus of Ito are large, at, greybrown patches and can be confused with bruising and other conditions (Fig. 20.5).
Caf au lait patches are part of neurobromatosis (Von Recklinghausens disease,
see page 199). Numerous at, light-brown macules, which vary from 0.5 cm2 to
4 cm2 are present all over the skin surface and characteristically in the axillae
alongside the neurobromata (Fig. 20.6).
Not dissimilar brown macules are found on the lips and around the mouth and
on the ngers in PeutzJeghers syndrome, accompanied by small-bowel polyps,
and in Albrights syndrome, in which there are associated bone abnormalities.
A very common type of localized hyperpigmentation is chloasma. This facial
pigmentation may be part of the increased pigmentation of pregnancy or may
occur independently. The cheeks, periocular regions, forehead and neck may be
affected in this so-called mask of pregnancy (Fig. 20.7).
Post-inammatory hyperpigmentation may be due to melanocytic hyperplasia
occurring as part of epidermal thickening in chronic eczema, particularly atopic
eczema. This is transient and of no real consequence.
It may also be due to the shedding of melanin from the damaged epidermis
into the dermis, where it is engulfed by macrophages. This tattooing may last
many months. It is seen in lichen planus (Fig. 20.8; see also page 144) and in xed
drug eruption (see page 95).
301
Figure 20.8 Dark patches

following resolution of
lichen planus.
Figure 20.7 Diffuse brown pigmentation
of the cheek in chloasma.
Summary
Melanin pigment is a complex, brown-black polymer,
synthesized from dihydroxyphenylalanine by DOPA
oxidase and tyrosinase in melanocytes in organelles
known as melanosomes. These organelles are
injected via dendrites into keratinocytes.
Oculocutaneous albinism is a recessively inherited
disorder in which there is a normal number of
melanocytes but a tyrosinase deciency. Albinos
have fair skin, white/yellow hair and light-blue eyes.
They are very sun sensitive and need careful
protection from the sun. In piebaldism, there is a
white forelock and white patches on the skin.
In vitiligo, there are well-dened, multiple patches of
depigmentation, which usually persist or spread but
can remit. It affects 12 per cent of the population
and appears to be autoimmune in origin. It may
respond to corticosteroids or PUVA.
Other causes of localized areas of depigmentation
include leprosy, in which the patches are
hypoaesthetic, pityriasis versicolor due to a
supercial yeast infection and pityriasis alba, which
is a kind of eczema in children.
Generalized hyperpigmentation (including the
mucosae and nails) due to excess pituitary
melanocyte-stimulating hormone occurs in Addisons

disease resulting from adrenal cortex disease or in
Nelsons syndrome after bilateral adrenalectomy. It
is also seen as part of acanthosis nigricans.
Other causes of generalized pigmentation include
primary haemochromatosis, hepatic cirrhosis,
Gauchers disease and renal failure.
Dark pigmentation due to non-melanin pigments
is seen in bruising (due to haemosiderin),
in alkaptonuria (due to homogentisic acid) and
after drug administration. Drugs that can cause
pigmentation are minoxycline, amiodarone and
agents containing silver, gold and mercury.
Chlorpromazine can cause a dusky, purplish
facial pigmentation; a golden-yellow colour is
evident in carotenaemia.
Mongolian spots, naevus of Ito and naevus of Ota
are slate-grey, localized patches due to a particular
kind of naevus.
Other localized areas of hyperpigmentation may
occur after skin inammation. Caf au lait patches
are seen in neurobromatosis. A more diffuse type
of facial hyperpigmentation that is mostly seen in
women is known as chloasma.
302
C H A P T E R
21
Management of
skin disease
303
Skin disability
305
305
309
Systemic therapy
311
314
Summary
316

DOES SKIN DISORDER AFFECT THE PSYCHE?
The skin is vital to interpersonal relationships. It is a vital part of our communications system. If it is destroyed or deranged in any way, unfriendly messages
are transmitted. Instead of the message, Here is a healthy, harmless member of
the human race, the signal from an abnormal skin is interpreted as announcing,
Beware of the contagion. There is a primitive dislike and distrust of individuals
with skin disease or skin deformity. Skin problems seem to engender genuine fear
and revulsion, perhaps as a hangover from primitive stages of human development when the avoidance of people with infected of infested skin had a survival
advantage.
Interestingly, patients with obvious skin disease are also very disturbed by its
appearance and tend to shun the company of others and become quite isolated.
These attitudes are known collectively as the leper complex. Reassurance and the
use of prostheses, hairpieces and cosmetic camouage should be encouraged rather
than sneered at.
Patients with obvious disease of exposed areas, widespread skin disease and
persistently itchy skin become depressed and need sympathy and general support,
but some may need psychotropic drugs and psychiatric help.
303
Management of skin disease
Figure 21.1 Dermatitis artefacta: an eroded area

on the arm with scars due to self-mutilation.
Figure 21.2 Dermatitis artefacta: a scarred area on

the thigh from self-induced injury.
DOES THE PSYCHE AFFECT THE SKIN?

A question frequently asked by patients is, Is it my nerves, doctor? For the most
part, there is no truth to this suggestion. Stress of all kinds can precipitate or aggravate all kinds of disease, including cardiovascular, gastrointestinal and skin diseases,
but there is very little evidence that psychological abnormality causes skin disorder.
The major exception is dermatitis artefacta, a skin disorder that is entirely selfinduced. The degree of insight varies among patients: some admit scratching,
picking or rubbing, but say they are unable to stop doing it; others hotly deny producing the injury to the skin.
The extent of the injury is itself varied. Clearly, in some patients the problem is
hysterical in the psychiatric sense. At one end of the scale, nodular prurigo (see page
120) can be said to be a form of dermatitis artefacta. At the other end of the scale,
there is a devastating injury resulting in serious permanent disability (Fig. 21.1).
In some cases, the artefactual injury is frank malingering for obvious gain
(Fig. 21.2). Psychotherapy and psychotropic drugs appear to offer very little and
the artefacts may persist for years.
DELUSIONS OF PARASITOSIS
This is a rare psychosis in which the individual believes that his or her skin is
infested with insects or worms. Often, sufferers will bring to the doctor rolled up
horn or other skin debris and point proudly to the infesting insect. They may
point to blemishes on the skin as evidence of their problem. These patients beliefs
304
are quite unshakeable, and beyond psychiatrists help. The drug pimozide has been
said to be helpful for patients with delusional parasitosis.
BODY IMAGE
We all have a particular view of ourselves and a special conceit over our own
visual worth. Curiously, some individuals have a distorted body image amounting
to a delusional belief. Too much hair, too little hair, discolorations and minor
blemishes can all become a major focal point of complaint. Dysmorphophobia is
a term used to describe this, not uncommon, condition.
Skin disability
Skin disease can be as disabling as disease of other organ systems. Disability from
skin disease consists of physical, emotional and social components. The physical
disability derives from decreased mobility due to the abnormal stratum corneum
present in eczema, psoriasis or the ichthyotic disorders. The abnormal horn lacks
extensibility and cracks when stretched. The abnormally stiff dermis in scleroderma
or scarring also affects mobility. The emotional disability stems from the psychological problems discussed above and can lead to serious depression and its consequences. The social disability stems from the isolation imposed by both the patients
themselves and society at large. It results in domestic and occupational problems.

Drugs for use topically are incorporated into vehicles, which include greasy singlephase ointments, creams, which are mostly oil in water, or water in oil emulsions
or aqueous lotions. Pastes are thick substances containing a particulate solid
phase; alcoholic lotions have some limited use, for example for scalp treatments;
gels are semi-solid, translucent water-lled or alcohol-lled matrices, which are
quite useful at times, for example for scalp disorders.
In general, ointments are prescribed for chronic scaling conditions, including psoriasis and persistent eczema; creams and lotions are prescribed for acute and exudative disorders. When the disorder is weeping and exudative, bathing and wet dressings
are required. Gauze dressings kept moist with saline or dilute potassium permanganate solution (1:8000) or aluminium subacetate solution (8 per cent) should be
used. Shampoos are helpful for psoriasis and seborrhoeic dermatitis of the scalp.
HOW MUCH TO PRESCRIBE?

It takes about 25 g to cover the body completely on one occasion with a cream or
ointment; 50 g would be sufcient for a topical treatment for a bilateral hand
dermatitis for a month. Clearly, 100 g would be needed for the hands and feet.
305
Emollients and cleansing preparations need to be prescribed in much larger

quantities.
ADVERSE SIDE EFFECTS FROM TOPICAL PREPARATIONS

(Table 21.1)
If a patient does not improve with the topical medicine prescribed, it may be because:
there is an adverse effect from use of the preparation (e.g. contact allergy)
the condition has been wrongly diagnosed
the patient has not used the medication
the condition is resistant to the treatment prescribed.
EMOLLIENTS
Emollients (moisturizers) act by occluding the skin surface with a lipid lm,
which prevents evaporation of water from the surface, allowing it to accumulate
within the stratum corneum. Emollients may be single-phase oils or greasy ointments, oil-in-water or water-in-oil emulsions, either as creams or lotions.
Emollients have important effects. They:
make the stratum corneum swell and atten so that the skin looks and feels
smoother
increase the extensibility of skin so that it cracks less
decrease binding forces between the horn cells and decrease scaling
decrease itch
have some intrinsic anti-inammatory properties, decrease epidermal mitotic
activity and have anti-prostaglandin synthetase activity.
Table 21.1 Adverse side effects of topical medications

Effect
Signicance
Allergic contact dermatitis

(dermatitis medicamentosa) to the
drug or a component of the vehicle
Eczematous rash at site of application,

e.g. from neomycin
Irritation of the skin
Eczematous rash at site of application,

e.g. from benzoyl peroxide
Photosensitivity
Erythematous or eczematous rash at

exposed site of application, e.g. from a
halogenated salicylanilide antimicrobial
Acneiform folliculitis
Acneiform rash at site of application,

particularly in acne-prone areas
Absorption of drug or component of

the preparation
Systemic toxicities, dependent on

particular preparation
306
Uses of emollients
Emollients may be all that is required for patients with mild ichthyotic
disorders.
They are also useful for patients with eczema, particularly atopic dermatitis.
Emollients help patients with psoriasis and other chronic scaling dermatoses.
TOPICAL CORTICOSTEROIDS
There are numerous preparations containing topical corticosteroids, with different potencies (Table 21.2). Their predominant use is for eczematous dermatoses,
but they are also useful in psoriasis. They have marked anti-inammatory and
antiproliferative effects. A major part of their action is in inducing lipocortin the
endogenous inhibitor of phospholipase A2 which is important in the generation
of eicosanoid compounds involved in the inammatory process.
Adverse side effects from topical corticosteroids (Table 21.3)
If enough corticosteroid is absorbed, there is suppression of the pituitaryadrenal

axis and adrenal atrophy. If even more is absorbed, a Cushingoid-like state can
develop (Fig. 21.3). A general guideline is that not more than 50 g 0.1 per cent
betamethasone 17-valerate ointment or cream should be used per week, or not
more than 30 g 0.1 per cent clobetasol 17-propionate.
Table 21.2 Classication of corticosteroids according to potency
Category
Activity
Examples
Mild (weak)
Hydrocortisone
Clobetasone butyrate
Moderately potent
Flurandrenolone
Desoxymethasone
Potent
Betamethasone-17-valerate
Fluocinolone acetonide
Very potent
Clobetasone-17-propionate
Halcinonide
Ulabetasol
Table 21.3 Side effects of topical corticosteroids

Absorption and pituitaryadrenal axis suppression and hypercortisonism
Skin-thinning effects causing telangiectasia, striae and fragility
Depressed wound healing
Masked infection, particularly ringworm (tinea incognito)
Miscellaneous, including acne, hirsutes and depigmentation
307
Figure 21.3 Iatrogenic Cushings syndrome due to the

use of large amounts of potent topical corticosteroid
(uocinolone acetonide) over a 3-year period.
Figure 21.4 Striae distensae from the use of potent

topical corticosteroids over a 6-month period.
The effects on the skin include:
skin thinning and striae (Fig. 21.4), resulting from the wasting action of corticosteroids on the dermal connective tissue
masked infection, particularly ringworm, resulting in extensive and unusualappearing ringworm (tinea incognito).
Note. Dilution of proprietary preparations is not advised because the formulations are complex and the important excipients are also diluted and may be ineffective when the dilution is made. Dilution does not necessarily decrease the effect
proportionately.
Case 22
Jeremy, aged 9, had had eczema since he was a few weeks of age, but it had
markedly worsened in the past 4 months, as had his asthma. Apart from the
obvious severe eczema, he had marked xeroderma. He started to improve when
he was treated regularly with emollients two or three times per day. He was also
helped by the use of a weak corticosteroid (clobetasone butyrate) twice daily and
a strong corticosteroid applied to the sites where there was severe eczema
(mometasone furoate) once daily. Care was taken to ensure that he did not use
excessive amounts of corticosteroids, in order to avoid the problems of skin
thinning and pituitaryadrenal axis suppression.
308
TOPICAL ANTIMICROBIAL AGENTS

It should be remembered that:
All that weeps and contains pus is not infected: many inamed skin disorders
are exudative but not infected.
Some imidazole and older halogenated phenolic compounds may irritate;
some antibiotics (e.g. neomycin) sensitize.
It is quite easy to induce bacterial resistance, and agents that may be used
systemically should not be used topically.
Amongst the safest and most useful compounds for bacterial and fungal infections are the imidazoles (e.g. econazole, miconazole, isoconazole), the triazoles
(naftine, terbinane) and povidone iodine. The antibiotic mupirocin is very
useful. Aciclovir, famiciclovir and idoxuridine are antiviral preparations used for
herpes simplex, the rst of these also being used for herpes zoster.

The surgical aspects of dermatology are increasingly important in dermatological
practice.
There is a growing demand for the removal of moles, seborrhoeic warts and
similar benign lesions.
The incidence of skin cancers of all types is increasing.
There is increasing demand and ability to treat the skin changes of
photodamage.
BIOPSY
The removal of a small fragment of skin tissue by trephine (punch biopsy) for
routine histological preparation for electron microscopy, immunouorescence or
microbial culture is usually adequate. Sharp, disposable trephines are available of
26 mm in diameter. Sutures are not necessary for biopsies of less than 4 mm
diameter taken this way, and only occasionally for 4 mm trephines. The following
are useful tips for taking biopsies.
Choose a new or typical lesion or the edge of an established lesion.

It may be necessary to biopsy at different times or to sample different
lesions.
Handle the biopsy as gently as possible.
Take care when biopsying human immunodeciency virus (HIV)-positive and
hepatitis B-positive patients the laboratories need to be notied beforehand.
Patients with bleeding diatheses and heart disease may need prophylactic
treatment.
309
ABLATIVE PROCEDURES
These are mainly used to treat seborrhoeic and viral warts and solar keratoses, but
also for minor, benign, localized lesions.
LASER TREATMENT
Lasers are high-intensity, coherent light sources of particular wavelengths, and are
employed for their destructive capacity. The particular tissue effect is inuenced
by the energy, the wavelength and the pulse duration of the emission, as well as by
the colour, thickness and depth of the tissue. Lasers are particularly useful for the
destruction of vascular birthmarks, but other kinds of lesions can also be tackled.
CURETTAGE AND CAUTERY

Sharp, spoon-shaped curettes or disposable ring curettes are used. After curettage,
the base is lightly touched with the tip of an electrocautery loop. Local anaesthesia is required beforehand. Curetted tissue should be examined histologically.
CRYOTHERAPY
This is used to treat viral warts and solar keratoses. A device supplying a ne spray
of liquid nitrogen is often used. The frozen skin turns snow white and needs to
stay this colour for 1520 seconds before tissue destruction is complete.
Caution is required when treating lesions on the ngers, as the digital nerves
can be damaged. Patients must be warned to expect pain and blistering at the
frozen site and be told to keep the site covered.
SHAVE EXCISIONS
This procedure is only suitable for benign, raised, dome-shaped lesions, such
as stable melanocytic naevi, as some abnormal tissue is left behind. After local
anaesthesia, the lesion is shaved off ush with the skin surface with a sharp scalpel.
The raw base is then lightly cauterized with an electrocautery loop. The tissue
removed is sent for histological examination.
EXCISION OF SMALL TUMOURS

Benign moles, dermatobromas and small basal cell carcinomas are examples of
lesions that can be easily removed by elliptical incisions around the lesion. Margins
of at least 3 mm need to be left at the sides of the lesion. The margins of the excision
are then sutured without tension, using a silk or synthetic suture material. If the
310
Systemic therapy
incision is parallel to Langers lines on the limbs and trunk but in the crease lines on
the face, scarring should be minimal. Keloid scars sometimes develop in patients aged
1230 years with excisions over the shoulders, upper arms and front of the chest.
Systemic therapy
(see Table 21.4)
In many cases, topical treatments are also available and decisions as to whether to
use a topical or a systemic agent need to be made. Some of the considerations are
as follows.
Systemic agents usually carry a greater risk of adverse side effects than topical
agents.
Systemic agents tend to have more potent therapeutic effects than topical
agents.
Many patients prefer a topical agent because they fear the side effects of
systemic treatment.
Some patients dislike using topical treatment and would prefer to take the risk
of side effects.
Topical treatment is impracticable in patients with widespread skin disease and
in the elderly and inrm.
The options need to be discussed with the patient.
SYSTEMIC CORTICOSTEROIDS
If these are needed, both the risks and the benets of such treatment should be
understood by all. Their action is predominantly suppressive by virtue of their
anti-inammatory properties. Systemic (and very potent topical) corticosteroids
can precipitate pustular psoriasis.
RETINOIDS
Although the usage of isotretinoin and acitretin differs, the precautions and side
effects are quite similar. There is a serious danger of teratogenicity if the drug is
given to a woman in the reproductive age group, and contraception is important.
Acitretin is mostly excreted quite quickly, but in the presence of alcohol is back
metabolized to the, now withdrawn, etretinate, which is stored in the fat and
detectable in the blood for 23 years. Contraception is required for this period.
Particular care must be taken with isotretinoin, as this drug is given for severe
acne and many young women are exposed to it. The mode of action of the
retinoid drugs is uncertain, but there appear to be fundamental effects on cellular
differentiation.
Patients on retinoids require monitoring for hepatotoxicity and elevation of
serum lipids every 48 weeks, and for bone toxicity annually.
311
312
Table 21.4 Details of systemic drugs

Drug
Usual dose
Main indications
Main side effects
Comments
Corticosteroids
550 mg daily
(prednisolone
equivalent)
Severe eczema, severe

drug reactions, severe
autoimmune disease and
hypersensitivity disorders,
bullous diseases
Hypertension, diabetes,
osteoporosis, psychosis,
infections, gastrointestinal,
bleeding skin thinning and striae,
adrenocortical suppression
Lowest dose possible is needed;

monitoring 4-weekly when
stabilized, more frequently early
in treatment; caution is needed on
stopping treatment because of
adrenocortical suppression
gradual reduction in dose is
necessary; dose needs to
increase during intercurrent illness
0.51.0 mg/kg
body weight daily
Severe psoriasis and

disorders of keratinization,
multiple non-melanoma
skin cancers
Minor: cheilitis, drying of oral/

nasal/ocular mucosae, diffuse
hair loss, paronychiae, pruritus
Major: teratogenicity,
hepatotoxicity, rise in serum lipids,
bone toxicity hyperostosis
and ossication of ligaments
Effects start after 4 weeks;

relapse is usual after stopping;
careful monitoring is required
every 48 weeks
0.51.0 mg/kg
body weight daily
Severe acne
As above
Effects start after 4 weeks; initial

aggravation is common; relapse
after stopping is unusual; careful
monitoring is required monthly
over a 4-month course of
treatment
Retinoids
Acitretin
Isotretinoin
Methotrexate
525 mg weekly
Severe psoriasis (pustular

erythrodermic, arthropathic
and severe recalcitrant
plaque type), pemphigus/
pemphigoid
Hepatotoxicity with eventual

brosis, myelotoxicity; nausea
and mucositis may occur as
acute effects
Regular monitoring is required

(48-week intervals); liver biopsies
are required after a cumulative
dose of 1.5 g; may be given in
combination with steroids for
bullous disease
Azathioprine
50150 mg daily
Lupus erythematosus and

other autoimmune
disorders, pemphigus/
pemphigoid
Nausea, myelosuppression
Often used in combination with

corticosteroids; monitoring is
required to check on blood picture
every 48 weeks
Cyclosporin
25 mg/kg body
weight daily
Severe psoriasis
(erythrodermic or
recalcitrant plaque type),
severe atopic dermatitis
Renal toxicity and hypertension;

nausea and hirsutes are
sometimes a problem; over the
long term, development of
neoplastic disease is a possibility
Potent immunosuppressive agent;

interactions with ketoconazole
may occur; monitoring 46 weekly
is advised
Dapsone
25150 mg daily
Leprosy, dermatitis
herpetiformis
Haemolysis, methaemoglobinaemia, Monitoring every 48 weeks is

sulphaemoglobinaemia, xed
advised
drug eruption; a granulocytosis
is recorded
313
METHOTREXATE
This is an antimetabolite that effectively stops cell division by blocking DNA synthesis. It also has many other metabolic effects. It is used both for its antiproliferative
actions and for its immunosuppressive effects. Patients require regular monitoring
for myelotoxicity and hepatotoxicity every 48 weeks and may need liver biopsies
after a cumulative dose of more than 1.5 g because of the frequency of serious liver
toxicity, particularly in those who abuse alcohol.
AZATHIOPRINE
This is an antimetabolite that also blocks DNA synthesis, whose prime use in dermatology is for its immunosuppressive activity. As with methotrexate, patients on
azathioprine require regular monitoring for myelotoxicity. Before use, the patient
should be checked for an inherited enzyme defect (thiopurine methyl transferase)
to avoid serious toxicity.
CYCLOSPORIN
This drug blocks lymphokine synthesis by lymphocytes. It is a very potent
immunosuppressive agent. Patients on the drug should be monitored for renal
toxicity and hypertension every 48 weeks.
DAPSONE (DIAMINOSULPHONE)
The mode of action of this drug is unclear. Its antimicrobial effects may be unrelated to its anti-inammatory activity. It causes haemolysis and methaemoglobinaemia and is myelotoxic.
ANTIFUNGALS
Griseofulvin, terbinane and itraconazole are effective against dermatophyte
infections. Itraconazole, uconazole and ketoconazole are effective against
infections with yeast-like micro-organisms. The doses and side effects are given
in Table 21.5.

Many patients with psoriasis and some with acne and atopic dermatitis improve
in the summertime after being out in the sun. It is the ultraviolet portion of the
solar spectrum (see page 27) that seems to aid these patients, and articial sources
314
Table 21.5 Doses and side effects of antifungal agents

Drug
Dose
Indication
Side effects
Griseofulvin
0.51.0 g daily
Ringworm infection only
Headaches, photosensitivities
Ketoconazole
200 mg daily
Systemic mycoses, severe

ringworm and yeast infections
Nausea, rashes, headaches,

liver damage in the elderly
Amphotericin
250 mg/kg daily by

i.v. infusion
Systemic candidiasis
Multiple toxicities including

renal, neurological and hepatic
Fluconazole
50 mg daily
Candidiasis, especially in
immunosuppressed patients
Nausea, rash
Itraconazole
100200 mg daily
Ringworm and yeast infections
Nausea
Terbinane
250 mg daily
Ringworm and onychomycosis
Nausea, rash
of ultraviolet radiation (UVR) are often used in treatment. Natural sunshine can
also be used if the local weather conditions permit. Special spas have been established at the Dead Sea in Israel, around the Black Sea and elsewhere.
Treatment with the sunburn part of the UV spectrum (UVB: 280320 nm) is
sometimes used to treat patients with psoriasis. Caution is necessary to prevent
burning in the short term and chronic photodamage and skin cancers in the long
term by giving the minimum dose of UVR necessary to clear the patients problems.
PUVA treatment
A more usual form of phototherapy in recent years is photochemotherapy with

long-wave UVR (UVA) known as PUVA. In this treatment, the skin is photosensitized with psoralen drugs, given either orally 2 hours before irradiation or
topically (in a bath) immediately before the UVR.
The oral drug used is mostly 8-methoxy psoralen, given in a dose of approximately 0.6 mg/kg body weight per day. Photochemotherapy with UVA has become
a standard treatment for patients with severe and generalized psoriasis and is successful in 7080 per cent of patients within 68 weeks. Usually, treatment is given
two or three times per week, starting at a low dose and gradually increasing the
dose until a good effect is obtained.
Patients with T-cell lymphoma of the skin (mycosis fungoides, Szary syndrome)
and some with atopic eczema also benet.
Burning is a danger, and sun-sensitive patients must be treated very carefully
with low doses. Nausea is common and due to the psoralen. Dry skin is also a side
effect in the short term. Unfortunately, it has been found that some 810 years
after high-dose PUVA treatment, there is a greatly increased incidence of skin
cancers particularly squamous cell carcinoma. Other forms of skin cancer and
chronic photodamage also seem to be increased after UVA.
Goggles or glasses that block UVA must be used during treatment and for
24 hours afterwards to prevent cataracts. Male patients need to cover their external genitalia because of the risk of neoplasia.
315
Summary
The skin is important in communication and there
is fear and dislike of skin disorders, causing social
isolation and depression in patients.
Stress may precipitate but not cause skin disorders.
Patients may produce a variety of lesions (dermatitis
artefacta). Rarely, patients may harbour a delusion
that their skin is infested by insects.
Dysmorphophobia describes the problem of
peoples distorted self-image (e.g. their nose is
too big, they have too much hair).
Skin disease may be both physically and
emotionally disabling.
In general, ointments are used for chronic scaling
disorders, whereas creams and lotions are used
for acute and exudative disorders.
Emollients occlude the skin surface, prevent
evaporation and cause a build up of water in the
stratum corneum. They soothe, smooth and soften
the skin. They have some anti-inammatory actions
and enhance desquamation. They are helpful for
patients with eczema, psoriasis and ichthyosis.
Topical corticosteroids are absorbed and may cause
pituitaryadrenal axis suppression with adrenal
cortical atrophy if appreciable amounts are applied
(e.g. if more than 50 g of betamethasone valerate

ointment or more than 30 g of clobetasol
propionate ointment are used per week).
Topical corticosteroids also cause skin thinning
and marked infection.
Imidazoles and povidone iodine preparations are
amongst the safest and most useful of the topical
antimicrobial agents.
Skin surgery is a growing area of work for
dermatologists because of a growing demand for
the removal of moles, warts and other blemishes.
In addition, surgical techniques, laser treatments
and cryotherapy have become increasingly
sophisticated.
Potent systemic therapies are often available, but
are more likely to cause signicant adverse side
effects. These include the systemic corticosteroids,
the oral retinoids, methotrexate, azathioprine,
cyclosporin and dapsone.
Oral antifungal agents include terbinane,
griseofulvin and itraconazole.
Phototherapy may be the most suitable form
of treatment for generalized skin disease.
This includes PUVA, UVB and spa treatments.
316
Bibliography
Books of interest
Adler, M.W. (ed.) 1990 ABC of Sexually Transmitted Disease. London: BMJ
Publishing Group.
Ashton, R.E. (ed.) 1992 Differential Diagnosis in Dermatology (second edition).
Oxford: Radcliffe Medical Press.
Darmon, M. and Blumenberg, M. (eds) 1993 Molecular Biology of the Skin: the
keratinocyte. London: Academic Press.
Freinkel, R. and Woodley, D. (eds) 2001 The Biology of Skin. Carnforth: Parthenon.
Harper, J. (ed.) 1990 Handbook of Paediatric Dermatology. London: Butterworths.
Hawk, J.L.M. (ed.) 1999 Photodermatology. London: Arnold.
Levene, G.M. and Goolamali, S.K. (eds) 1986 Diagnostic Picture Tests in Dermatology.
London: Wolfe.
Lowe, N. and Marks, R. 1998 Retinoids. A Clinicians Guide (second edition).
London: Martin Dunitz.
McKee, P.H. 1999 Essential Skin Pathology. St Louis, MI: C.V. Mosby.
Marks, R. (ed.) 1981 Coping with Psoriasis. London: Sheldon Press.
Marks, R. (ed.) 1992 Eczema. London: Martin Dunitz.
Marks, R. (ed.) 1999 Skin Disease in Old Age (second edition). London: Martin
Dunitz.
Marks, R. 2001 Sophisticated Emollients. Stuttgart: Thieme International.
Marks, R. and Leyden, J.J. (eds) 2002 Dermatologic Therapy in Current Practice.
Marks, R. and Ortanne, J.P. 1999 Photodamaged Skin: clinical signs, causes and
management. London: Martin Dunitz.
Marks, R., Dykes, P.J. and Motley, R. 1993. Clinical Signs and Procedures in
Dermatology. London: Martin Dunitz.
Marks, R., Leveque, J.L. and Voegeli, R. (eds) 2002 The Essential Stratum Corneum.
Reonigk, R.K. and Roegnik, H.H. (eds) 1993 Surgical Dermatology. London:
Martin Dunitz.
Sharvill, D.E. (ed.) 1988 Skin Signs of Systemic Disease. London: Pocket Picture
Guides.
317
Bibliography
Reference books
Braun-Falco, O., Plewig, G. et al. 2000. Dermatology. Berlin: Springer-Verlag.
Champion, R.H., Burton, J.L., Burns, D.A. and Breathnach, S.M. (eds) 1998 Textbook
of Dermatology (sixth edition, in four volumes). Oxford: Blackwell Science.
Goldsmith, L.A. (ed.) 1991 Physiology, Biochemistry and Molecular Biology of the
Skin (second edition). Oxford: Oxford University Press.
McKee, P.H. 1989 Pathology of the Skin with Clinical Correlations. Philadelphia,
PA: J.B. Lippincott Co.
Selected articles and reviews

Barbargallo, J., Tager, P., Ingleton, R., Hirsch, R.J. and Weinberg, J.M. 2002:
Cutaneous tuberculosis. Diagnosis and treatment. American Journal of Clinical
Dermatology 3, 319328.
Chartier, M.B., Hoss, D.M. and Grant Kels, J.M. 2002: Approach to the adult
female patient with diffuse non scarring alopecia. Journal of the American
Academy of Dermatology 47, 809818.
English, J. 2001: Current concepts in contact dermatitis. British Journal of
Huang, C.L., Nordlund, J.J. and Boissy, R. 2002: Vitiligo. A manifestation of apoptosis? American Journal of Clinical Dermatology 5, 301308.
Kroumpouzos, G. and Cohen, L.M. 2001: Dermatoses of pregnancy. Journal of the
American Academy of Dermatology 45, 119.
Leung, D.Y.M. and Soter, N.A. 2001: Cellular and immunologic mechanisms in
atopic dermatitis. Journal of the American Academy of Dermatology 44(1), S1S12.
Marks, R. 1999: The signicance and measurement of scaling. Journal of Dermatology
26, 713717.
Nakagawa, S. and Bos, J.D. 2001: Role of Langerhans cells in the skin. Whats new?
Journal of the European Academy of Dermatology and Venereology 15, 399401.
Nickolff, B.J. 1999: The immunologic and genetic basis of psoriasis. Archives of
Takigawa, M. 2002: Histamine and cutaneous allergy: old friend, new player.
Journal of Dermatology 20, 263266.
318
Index
Note: page numbers in bold refer to gures, page numbers in italics refer to information contained in tables
ablative procedures 310
acantholysis 92
acanthoma, clear cell 188, 189
acanthosis nigricans 283, 283, 299
aciclovir 51, 53, 100, 309
acitretin 311, 312
for chronic discoid lupus erythematosus 80
for lichen planus 147
for non-bullous ichthyosiform erythroderma
250
for psoriasis 141
for solar keratoses 210
acne 14961
clinical course 1523
clinical features 14951, 150, 151, 152
in Cushings syndrome 289
denition 149
disabling effects of 22
epidemiology 1534
pathology/aetiopathogenesis 1567, 156, 158
prevalence 2, 149
sites affected 152, 153
and sun exposure 34
treatment 15761, 159
systemic 15961, 159
topical 1579, 159
types 1546
acne from drugs and chemical agents
1545, 154
acne fulminans 15051
chloracne 1556
cosmetic 27, 27, 155, 155
cystic/nodulistic 15051
excoriated 156
infantile 154, 154, 2312, 232
oil acne 155, 155
acneiform folliculitis 155, 155
acrodermatitis chronica atrophicans 49
acrodermatitis continua 135
actinomycosis 43
adapalene 159
Addisons disease 14, 289, 289, 299
adrenalin 68, 93
agammaglobulinaemia, infantile 101
ageing process 234
see also old age; photodamage
extrinsic ageing 234
intrinsic ageing 234
AIDS (acquired immune deciency syndrome)
97100
see also HIV
and acquired ichthyosis 284
bacterial infections in 64, 99
fungal infections in 43, 98
pruritus in 99
psoriasis in 100, 138
scabies in 100
seborrhoeic dermatitis in 98, 98, 100, 100, 116
skin cancer in 99, 100, 209, 224

treatment of skin conditions in 100
viral infections in 52, 53, 989
albinism 2967
oculocutaneous 2967
Albrights syndrome 301
alcaptonuria 1314
allergens, in allergic contact dermatitis 123, 124,
124, 125
allografts, renal 101
allylamines 42
alopecia see hair disorders, alopecia
alpha-2B interferon 210
alretin 224
aluminium oxide preparations 159
aluminium subacetate solution 113
amiodarone 300
amiphenazole 43
amphotericin 315
ampicillin 94, 117
amyloidosis 262, 263
anaemia 176
anaphylactic shock 67, 93
androgenization (virilization/masculinization)
2312, 276, 28990, 290
androgens 154, 157, 270
aneurysm, capillary 196
angioedema 715, 72, 93
angiokeratoma 196, 196
angiokeratoma corporis diffusum 196
angioma (vascular malformations) 1947
capillary 195, 195
senile 196, 196
anhidrotic ectodermal dysplasia 257
anisotropic nature of the skin 256
Anthralin (dithranol) 139, 139
anthrax 46
anti-androgens 158, 161
anti-inammatory agents 158
antibodies 889, 89, 92, 111
antifungals 314
doses 315
side effects 315
antigens 85
antihistamines 68, 75
antimicrobial agents
see also specic drugs
systemic 313, 314
for acne treatment 15960, 159
for atopic dermatitis 114
topical 309
for acne treatment 157, 158, 159
arachis oil 231
argyria 300
arsenic 300
arterial grafting 178
arteriovenous malformation 181, 181
aspirin 74, 94
asthma 10910
ataxia telangiectasia 101
atherosclerosis 178
autoimmune disorders (collagen vascular
disorders) 7780, 100
see also lichen planus; lupus erythematosus
azathioprine 313, 314
for bullous pemphigoid 88
for chronic actinic dermatitis 32
for dermatomyositis 84
for eczema 236
for pemphigus 92
for polymorphic light eruption 33
for systemic lupus erythematosus 79
for systemic sclerosis 82
azelaic acid 168
bacterial skin infections 4450
see also specic infections
acute 445
in AIDS patients 64, 99
anthrax 46
carbuncles/furuncles 45
leishmaniasis 4950, 50
leprosy 489, 299
lupus vulgaris 467
Lyme disease 49
sarcoidosis 478, 478
tuberculosis 467, 176, 181
ulceration 172, 176, 181
balanitis xerotica obliterans 83
bandages
compression 177
rm pressure 198
basal cell carcinoma (basal cell epithelioma)
21417
clinical features/types 21516, 215, 215
morphoeic 215, 216, 216
nodulocystic 215, 215, 215
pigmented 215, 215, 215
supercial 132, 215, 216, 216
ulcerative 176, 182, 215, 215, 215
denition 214
degree of inltration 17
in the elderly 236
epidemiology 217
pathology/aetiopathogenesis 216, 217
treatment 217
basal cell naevus syndrome (Gorlins syndrome)
21718
baths, antimicrobial 113
Beaus lines 278
Beckers naevus 186, 186
bedbug (Cimex lectularius) 67
bee stings 67
benzoyl peroxide 157, 232
betadine 44
319
Index
betamethasone 17-valerate 138, 307

biopsy 309
see also skin surface biopsy
for dermatitis herpetiformis 8990
for drug eruptions 93
for onchocerciasis 69
for pemphigus 88, 92
small-bowel mucosal 8990
for ulceration 182
birefringence 262
birthmarks, vascular
disabling effects of 22
treatment 204
types 1947, 1947
ulceration of 181
blacky (Simulium damnosum) 69
blastomycosis 43
bleeding, in venous ulceration 176
bleomycin 55
blepharitis, marginal 115
blepharoconjunctivitis 1645
blindness, river blindness 69
blistering disease 879, 88
subepidermal 889
blistering rashes 94
see also bullae
body image, dysmorphophobia 305
Bowens disease 132, 21011, 211
Breslows thickness technique 222
brownblack pigmentation
of the nails 278, 278
of the skin 1314, 13
bullae (blisters) 18, 18
see also blistering disease; blistering rashes
intraepidermal 18
subepidermal 18
and vesicant injury 27
bullous disease of childhood 89
bullous ichthyosiform erythroderma (epidermolytic hyperkeratosis) 2512, 251, 252
bullous pemphigoid (senile pemphigoid) 889,
88, 284
bullae 18, 18
variants 89
Buruli ulcer 47
caf au lait patches 199, 199, 256, 301, 301
calamine preparations 68, 240
calcipotriol 138, 141
candidiasis (moniliasis, thrush) 43, 241, 277
in diabetics 293
and napkin rash 230
canthexanthin 300
capillaritis 87, 87
captopril 94
carbamazepine 93, 94
carbaryl lotion 63, 64
carbuncles 45
carotenaemia 300
case studies
acne 161
AIDS patients 99
eczema 20, 236, 308
erythema multiforme 76
granuloma annulare 265
itchy rashes in pregnancy 241
lichen simplex chronicus 121
lichenication 20
napkin rash 229
necrobiosis lipoidica 286
non-melanoma skin cancer 205, 217
onycholysis 278
pattern alopecia 271

psoriasis 138
ringworm infections 42
scabies 62
seborrhoeic warts 205
sex-linked ichthyosis 249
solar UVR injury 28
topical corticosteroid use 308
venous ulceration 177
vitiligo 298
castration 270
chemical 270
cataract 141, 315
cavities, uid-lled 18, 1819
cellulitis 45
cephradine 45
chalazion 165
challenge test 93
chancroid (soft sore) 103
chemotherapy 210, 223
chicken pox (varicella) 51, 52, 241
chilblains 34
chloasma (melasma) 238, 239, 301, 302
chlorhexidine solutions 177
chlorinated naphthalenic compounds 1556
chloroquine 260
chlorpromazine 300
chymotryptase protease enzyme 4
circinate balanitis 102
circulation, hyperdynamic 133
circumcision 83
cirrhosis 300
Clark staging method 222
clear cell acanthoma (degos acanthoma) 188, 189
clindamycin 159
clobetasol 17-propionate 307
clobetasone 17-butyrate 112, 231
clofazimine 49
clotrimazole 116
cold injury 34
collagen 67, 234
naevi of 2001
collodion baby 249, 251, 2524, 253
acquired ichthyosis 254
harlequin fetus 253
Refsums syndrome 253
comedolytic agents 157, 158, 159, 159
comedones (horny plugs) 14950, 150, 1557, 155
giant 204
comparator principle 13
complement component C3 88, 92
condylomata, perianal 103, 103
Congo red stain 262
coproporphyrins 259, 260
corneocytes (horn cells) 24, 5, 243, 244
desquamation 23, 3, 4, 14
corrosive injury 27
corticosteroids
intralesional 121
systemic 311, 312
for eczema 236
use in infants 227
for urticaria 75
topical 3078
for allergic contact dermatitis 125
for atopic dermatitis 112, 231
as cause of acne 155
as cause of perioral dermatitis 169
dilution of 308
for discoid eczema 118
for hypertrophic scar 198
320
for juvenile plantar dermatosis 233

for lichen sclerosus et atrophicus 83
for lichen simplex chronicus 121
for napkin rash 230
potency classication 307
for psoriasis 138, 139
and rosacea 1678, 168
side effects 3078, 307, 308
and tinea incognito 42
for vitiligo 298
cosmetic acne 27, 27, 155, 155
cradle cap 116, 231
CREST syndrome 81
CRST syndrome 81
cryostat sectioning 3, 3
cryotherapy 310
for benign tumours/moles/birthmarks 204
for ulcers 50
for viral warts 55
curettage and cautery 310
for basal cell carcinoma 217
for benign tumours/moles/birthmarks 204, 205
for keratoacanthoma 214
for leishmaniasis 50
for lentigo maligna 220
for molluscum contagiosum 56
for viral warts 55
Cushings syndrome 2889, 288, 289
iatrogenic 307, 308
cutaneous vascularity 239, 239
cyanoacrylate adhesive (crazy glue) 38, 61
cyclosporin 313, 314
for eczema 236
for pemphigus 92
for psoriasis 14041
for pyoderma gangrenosum 181
for systemic sclerosis 82
cylindroma 1867, 187
cyproterone acetate 161
cystic/nodulistic acne 15051
cysts 2024, 203
dermoid 204
epidermoid (sebaceous) 203, 203
follicular retention 204
milia 203, 203
pilar (tricholemmal) 2034, 203
sebocystoma multiplex (steatocystoma
multiplex) 204
Dapsone (diaminosulphone) 313, 314
for dermatitis herpetiformis 90
for leprosy 49
for pemphigoid gestationis 241
side effects 95, 300, 313, 314
Dariers disease (keratosis folliculitis) 2545,
254
Dariers sign 201
de SanctisCaccione syndrome 218
decubitus ulcer 173, 1789, 179
deep fungus infections 43, 98, 181
dehydration 4, 133, 228
delavudine 100
delusions, of parasitosis 3056
dematobromasarcoma 224
Demodex folliculorum 166
Denny Morgan folds 109, 109
dermal papillae 4, 5
Index
dermatitis see eczema

dermatobroma (histiocytoma, sclerosing
haemangioma) 1978, 197
hypertrophic scar 1978, 198
keloid scar 198, 198
dermatomes 52, 53
dermatomyositis 164
associated with malignant disease 2845
clinical features 83, 84
erythema 13, 13
laboratory ndings 834
dermatophyte infections 37, 3943, 98
dermatosis papulosa nigra 184
dermis
ageing 234
chronic photodamage to 29, 30
depth of invasion of in malignant melanoma
2212
in rosacea 166
structure/functions 68, 7
junction with the epidermis 4, 5
mechanical properties 256
nerve structures 78, 8
vasculature 7, 7
dermographism 72, 73, 74
oedema in 17, 17
desaturase deciency 112
desmosomes 34
desoxymethasone 112
desquamation (shedding)
failure 244
process of 3, 3, 4, 14, 243, 244
diabetes
skin manifestations of 2868, 286
candidiasis 293
granuloma annulare 287
necrobiosis lipoidica 286, 287
pruritus 288, 293
skin infections 288
ulceration 287, 287
xanthomata 2878, 287
Dianette 161, 270
diclofenac 210
differentiation see keratinization
dioxin 1556
diphencyprone 273
disability, due to skin disease 213, 2445, 305
discoid lupus erythematosus 22, 22, 275, 275
displastic naevus syndrome (atypical mole
syndrome) 193, 194
dithranol 139, 141, 273
Dithrocream139
diuretics 94
Dovobet 138
doxycycline 160, 167
drainage
pustular 45
venous 1767
dressings 177, 305
wet 88, 116
drug eruptions 925
exanthematic 94
xed drug 95, 95, 301
photosensitivity rashes 945, 94, 95
severe life-threatening 93
tests for 93
treatment 95
drug resistance 49
drug-induced hyperpigmentation 300
drug-induced immunodeciency 1001, 101
dry skin disorders 15, 235
dysmorphophobia 305
dysplasia
see also photodysplasia
anhidrotic ectodermal 257

epidermal 29
ear deformities 252, 253
eccrine poroma 1878, 187
ecthyma 44
eczema (dermatitis) 10527
atopic dermatitis 10514, 235
associated disorders 10910
clinical features 1079, 107, 108
clinical variants 109, 110
complications 11011
denition 105
disabling effects of 23, 23
epidemiology/natural history 2, 111
infantile 228, 23031
laboratory ndings/aetiopathogenesis
11112
management 11214
pruritus in 20
and sun exposure 34
case studies 20, 236, 308
chronic actinic (persistent light reaction;
actinic reticuloid syndrome) 32, 32
common types 106
contact dermatitis 1215
allergic contact dermatitis 17, 121, 1225,
123, 125
primary irritant dermatitis 1212, 121, 122
dermatitis artefacta 304, 304
dermatitis herpetiformis
associated with gastrointestinal disease 292
bullae 18, 19
laboratory ndings 8990, 89, 90
treatment 90
discoid eczema (nummular eczema) 11718,
132, 235
denition 117
differential diagnosis 118, 118
epidemiology/natural history 117
treatment 118
eczema craquele (asteatotic eczema) 11819,
119, 235
in the elderly 2356
endogenous/constitutional 105
hyperpigmentation in 301
impetiginzation in 44
infectious eczematoid dermatitis 115
inammatory dermatitis 26, 26
due to injury 105
juvenile plantar dermatosis 233
lichen simplex chronicus (circumscribed
neurodermatitis) 11921, 120, 131, 132
oedema in 18, 18
in old age 2356
painful 21
perioral dermatitis 163, 1689, 169
photodermatoses 314, 31, 323, 235, 291
scaling in 15, 108, 11415, 114
seborrhoeic dermatitis 11417, 131, 22930,
235
in AIDS patients 98, 98, 100, 100
denition 114
infantile 22930
natural history/epidemiology 116
treatment 11617
due to toxic substance damage 26, 26
venous eczema (gravitational eczema; stasis
dermatitis) 1256, 126
in venous ulceration 176
efavirenz 100
elastic tissue, naevi of 2001
elevation 176
emollients (moisturizers) 3067
for allergic contact dermatitis 125
for autosomal dominant ichthyosis 247
for bullous ichthyosiform erythroderma 251
for eczema 236
for napkin rash 230
250
for use in old age 235, 236
for use in pregnancy 240
for psoriasis 138
for rosacea 168
for venous eczema 126
for xeroderma 246
endarterectomy 178
endocarditis, subacute bacterial 86
endocrine diseases 2858
environmental hazards 2536
chronic photodamage (photoageing) 2934,
30
cold injury 34
heat injury 35
solar UVR injury 278
toxic substances 267
eosinophilic granuloma (EG) 266
epidermal differentiation see keratinization
epidermal dysplasia 209
epidermal naevus 185
naevus unius lateris 185, 185
epidermal photodysplasia 29
epidermis
ageing 234
chronic photodamage to 29
in necrolytc migratory erythema 282, 282
psoriatic 136, 137, 137
and solar keratoses 207, 209
structure/functions 1, 46, 5
junction with the dermis 4, 5
pigmentation 295
toxic substance damage to 26
tumours 1836
epidermodysplasia verruciformis 55, 55
epidermolysis bullosa 9091
dystrophic epidermolysis bullosa 91
epidermolysis bullosa simplex 9091
Epidermophyton 39
E. occosum 39, 40, 41
epitheloid angiomatosis 99
erosions 19
eruptive skin disorders 12
see also drug eruptions; specic disorders
erysipelas 445, 45
erythema (redness) 1213
annular 77
in bullous ichthyosiform erythroderma 251
buttery 78, 78
in dermatomyositis 83, 84
erythema ab igne 35, 35
erythema chronicum migrans 49, 77
erythema gyratum repens 77, 283, 284
erythema induratum 467
erythema multiforme 56, 756, 756, 93
bullae 18, 19
causes 76, 76
clinical features 75
treatment 76
erythema nodosum 48, 77, 77, 77
gurative 285
necrolytc migratory 2812, 282
321
Index
erythema (redness) cont.

in non-bullous ichthyosiform erythroderma
249
in rosacea 1623, 162, 168
erythromycin
systemic 102, 160, 167
topical 159
erythroplasia of Queyrat 211
erythropoietic porphyria 261
erythropoietic protoporphyria 261, 300
ethinyl oestradiol 161
etretinate 311
eumelanin 296
evaporimeters 227
excision 31011
see also shave excisions
of basal cell carcinoma 217
of dematobromasarcoma 224
of keratoacanthoma 214
of malignant melanoma 223
of squamous cell carcinoma 213
exclamation marks 272
excoriations (scratch marks) 20, 21
in atopic dermatitis 107, 107
infantile 2278, 230
exudate 17
factor XIII deciency 1723
famiciclovir 51, 309
fetus
see also collodion baby
effects of intercurrent skin disease on 24041
harlequin 253
brin 1745
brosis 175
laggrin 5, 247
nasteride 271
ag sign 291
ea bites 65
ucloxacillin 45, 233
uconazole 43, 100, 314, 315
uid-lled cavities 18, 1819
5-uorouracil 210
urandrenolone 112
follicles
in acne 14950, 152, 157
in atopic dermatitis 109, 110
bacterial infections of 45
functions/structure 2, 89, 9, 269
in pattern alopecia 270
sebaceous 152
follicular accentuation 143, 143
follicular retention cysts 204
follicular rupture 156, 157, 158
follicular tumours, benign 188
folliculitis 156, 156
acneiform 155, 155
keratosis folliculitis 2545, 254
oil folliculitis 27
papular 98, 98, 99
seborrhoeic 115
foot, soles of 23
foscarnet 100
frostbite 34
frusemide 94
functions of skin see structure/functions of skin
fungal skin infections 3743
see also pityriasis versicolor; tinea infections
in AIDS patients 98
deep fungus infections 43, 98, 181
furuncles (boils) 45, 49
ganciclovir 100
Gardeners syndrome 292
gastrointestinal diseases 292

Gauchers disease 300
genodermatoses 240, 2567
see also keratinization, disorders of
anhidrotic ectodermal dysplasia 257
neurobromatosis 16, 199200, 199, 256, 257,
301, 301
tuberous sclerosis 2001, 201, 256
ghost cells 188
globular eosinophilic bodies (molluscum bodies)
56, 56
glomerulonephritis, acute 44
glomus tumour 21, 197
gloves, electrically heated 34
glucocorticoids 1545
glucocorticosteroids 288, 289
glucogen storage disease 300
glutaraldehyde 55
gluten allergy 292
goggles/glasses 315
gold salts 80, 93, 94
gonococcaemia 86
gonorrhoea 102, 102
grafts
arterial 178
split skin fragment 177
gram-negative micro-organisms 176
gram-positive micro-organisms
gram-positive cocci 37, 157, 176
gram-positive lipophilic microaerophilic rods
37
gram-positive yeast-like organisms 37
granular cell layer, reduction of 246, 247
granuloma
eosinophilic 266
granuloma annulare 265, 265, 266, 287
pyogenic 197, 197
swimming pool 47
granulomatous plaque 46
gravitational syndrome 1737, 174
grenz zone 29
griseofulvin 42, 43, 314, 315
haemangioma, carvenous 195
haematological disorders 176, 181
haematological tests 182
haemochromatosis (bronzed diabetes) 262
primary 300
Haemophilus ducreyi 102
haemosiderin 13, 13
haemosiderosis, secondary 300
HaileyHailey disease (chronic benign familial
pemphigus) 255
hair cycle 273, 274
anagen 8, 9
catagen 8, 9
telogen 8, 9
hair disorders 26876, 270
alopecia (hair loss) 26876
alopecia areata 110, 2713, 271, 272
alopecia totalis 272, 272, 273
caused by chronic discoid lupus
erythematosus 79, 80
congenital alopecia 268
diffuse hair loss 273
pattern alopecia 26871
scarring alopecia 275, 275
telogen efuvium 273
due to tinea capitis 41, 41
traction alopecia 274, 274
congenital hypotrichosis 268
hair shaft disorders 2756, 275, 276
hirsutes 276, 290, 290
hair follicle canal 8, 9
322
hair follicles see follicles

hair matrix 8
hair regrowth 272, 272
HandSch
llerChristian disease (HSCD)
266
harlequin fetus 253
hay fever 10910
heat injury 35
heliotrope ower 13, 13
helminthic infestations of the skin 6970
hepatic disease 2923, 293, 300
hepatitis B 309
HermanskiPudlak syndrome 297
herpes simplex 5051, 51, 241
and atopic dermatitis 111
treatment 51
type I (facial) 5051, 51
type II (genital) 50, 51
herpes zoster (shingles) 51, 523, 52
bullae 19
pain in 21
Hetrazan (diethyl carbamazine) 6970
hidradenoma, nodular 187, 187
hirsutes 276, 290, 290
histamine release 71, 73
HIV (human immunodeciency virus) 97
see also AIDS
and biopsies 309
in pregnancy 241
and scabies 5960
hives see urticaria
Hodgkins disease 293
homogentisic acid 14
horn pearls 212, 213
human papillomavirus (HPV) 53, 53
and neoplasia 209, 213
Hutchinsons summer prurigo 33
hydantoinates 93, 94, 95
hydralazine 95
hydrocortisone
intravenous 93
topical
for eczema craquele 119
for napkin rash 229
for seborrhoeic dermatitis 116
for venous eczema 126
hydroxychloroquine 33, 80
hyperkeratosis 15
denition 14, 244
epidermolytic 251, 251, 252
in lamellar ichthyosis 252, 252
hyperlipidaemias 2624, 263, 288
hyperparathyroidism 293
hyperpigmentation 296, 299302
in Addisons disease 289, 289
in atopic dermatosis 109
generalized 299300, 300
localized 3012
caused by toxic substances 27
hypersensitivity
delayed 101, 234
to insect bites/stings 67, 68
to streptococcal antigens 85
in urticaria 74
in venous eczema 126
hypertension, venous 1737, 174, 175, 178
hypertrophic scars 1978, 198
hypochlorite solutions 177
hypopigmentation 27
in atopic dermatosis 109
generalized 2967
Index
in leprosy 48
localized 2979, 299
hypothermia, infantile 228
hypotrichosis, congenital 268
hypovitaminosis A 101
iatrogenic disorders 307, 308
ichthyosis 15, 244
acquired 99, 254, 284, 285
autosomal dominant 2467, 247
lamellar 252, 252
sex-linked 2479, 248
idoxuridine 51, 309
imidazole, topical 309
for candidiasis 43
for pityriasis versicolor 39
for ringworm infections 42
for seborrhoeic dermatitis 116, 230
imiquimod 210
immune system imbalances 111
immunocompromised patients
see also AIDS; HIV
congenital immunodeciency 101
and deep fungus infections 43
drug-induced immunodeciency 1001, 101
and herpes zoster 52, 53
and scabies 5960, 61
immunouorescence techniques 147
direct 88, 90
indirect 92
immunoglobulin A (IgA) 89
immunoglobulin E (IgE) 93, 111
immunoglobulin G (IgG) 88, 89, 92
immunologically mediated disorders 240
of the skin 7196
see also pemphigus
annular erythemas 77
autoimmune disorders 7780, 100
blistering disease 879, 88
dermatitis herpetiformis 18, 19, 8990,
8990, 292
dermatomyositis 13, 13, 834, 84, 164, 2845
drug eruptions 925, 301
epidermolysis bullosa 9091
erythema multiforme 18, 19, 56, 756,
756, 76, 93
erythema nodosum 48, 77, 77, 77
morphoea 823, 82
systemic sclerosis 8082, 81, 81
urticaria and angioedema 715
vasculitis group of diseases 847, 857
impetiginization 19, 20
impetigo contagiosa 44, 44
in vitro spectroscopic method 31
indomethacin 93
infantile agammaglobulinaemia 101
infantile skin problems 22733
atopic dermatitis 228, 23031
cradle cap 116, 231
functional differences 227
infantile acne 154, 154, 2312, 232
lip-licking cheilitis 233, 233
management problems 2278
napkin rash 22830
toxic epidermal necrolysis 2323
infections of the skin 3757
bacterial see bacterial skin infections
fungal 3743, 98, 181
as sign of diabetes 288
viral see viral skin infections
infestations 5865, 6970
aetiology/epidemiology 589
helminthic 6970
pediculosis 635, 63, 64, 65
scabies 20, 5863, 5961, 62, 100
inammatory skin conditions
inammatory dermatitis 26, 26
oedema 17
psoriasis 137, 138
inositol nicotinate 34
insect bites/stings 58, 6570
bedbugs (Cimex lectularius) 67
bees/wasps 67
diseases spread by 66
eas 65
methods of skin injury 66
mites 67, 67
mosquitoes 65, 66
onchocerciasis 6970, 69
ticks 67
and urticaria 678, 68, 745
interferons 214, 223
recombinant 55, 100
interleukin-2 223
ischaemic ulcers 173, 1778
isomorphic response (Koebner phenomenon)
21, 130
isoniazid 46
isotretinoin (13-cis-retinoic acid)
systemic 311, 312
for acne 16061
for non-bullous ichthyosiform
erythroderma 250
for rosacea 167
side effects 160, 161, 250, 311, 312
topical 159
itraconazole, systemic 314, 315
for AIDS infections 100
for pityriasis versicolor 39
for ringworm infections 43
Ivermectin 70
JarischHerxheimer reaction 104
jaundice 293
juvenile melanoma 194, 194
juvenile xanthogranuloma (JX) 2667
Kaposis sarcoma (idiopathic haemorrhagic
sarcoma) 99, 100, 2234, 223
KatzenbachMerritt syndrome 195
keloid scars 198, 198, 311
keratinization (epidermal differentiation)
disorders of 23, 24356
see also scaling
autosomal dominant ichthyosis 2467, 247
bullous ichthyosiform erythroderma
2512, 251, 252
collodion baby 249, 251, 2524, 253
Dariers disease 2545, 254
disability in 2445
ear deformities 252, 253
HaileyHailey disease 255
horn pearl formation 212, 213
lamellar ichthyosis 252, 252
non-bullous ichthyosiform erythroderma
24950, 250
pachyonychia congenital 256
primary 15, 15
secondary 15
sex-linked ichthyosis 2479, 248
tylosis 2556, 255
xeroderma 108, 21819, 219, 2456, 245,
246, 284
process of 3, 5, 243
keratinocytes
functions/structure 45, 296
large (cellules monstreuses) 211
and pigmentary incontinence 13
keratitis 165
keratoacanthoma (molluscum sebaceum) 214,
214
keratoconjunctivitis sicca 165
keratoderma blenorrhagica 102
keratolytic agents, topical
for Dariers disease 255
250
keratosis pilaris 246, 246
ketoconazole 100
systemic 423, 314, 315
topical 39
kwashiorkor 291
lactic acid 55
lamellar bodies (membrane-coating granules)
5
lamivudine 100
Langerhans cells
and ageing 234
in allergic contact dermatitis 125
in reticulohistiocytic proliferative disorders
2667
structure/functions 4, 6
Langers lines 26
laser treatment 310
leg, elevation 176
leiomyoma 21, 198
leishmaniasis 4950, 50
cutaneous component to visceral forms 50
cutaneous forms 49, 50
mucocutaneous forms 4950
leishmanin 50
lentigo maligna (Hutchinsons freckle) 21920,
219, 236
leper complex 212, 303
leprosy (Hansens disease) 489, 299
dimorphic 48
lepromatous form 489
multibacillary 48, 49
paucibacillary 48, 49
treatment 49
tuberculoid form 48
lesions
in acne 14951, 150, 151
in angioma 1945
in basal cell carcinoma 216, 217
of collagen and elastic tissue naevi 201
cystic 203, 204
denition 12
of granuloma annulare 265, 265
in Kaposis sarcoma 223, 224
in lentigo maligna 219
in lichen planus 144, 144
in malignant melanoma 222
in mastocytosis 202
in psoriasis 128, 129, 129
in rosacea 1623
in scabies 59, 59, 60
size/shape/thickness of 1517
annular (ring-like) 1617, 16
edges of 16
gurate 17
polygonal 17, 17
in squamous cell carcinoma 21112, 212
types
macules 15, 16
nodules 16
323
Index
lesions cont.
types cont.
plaques 15
tumours 16
LettererSiwe disease (LSD) 266
leucocytoclastic angiitis 85, 85
lhomme rouge 225
lice see pediculosis
lichen amyloidosis 262
lichen aureus 87
lichen planus 1447
aetiopathogenesis 1467, 146
clinical variants 1456
annular lichen planus 146
bullous lichen planus 146
hypertrophic lichen planus 145, 145
lichen nitidus 146
lichen plano-pilaris 146
denition 144
erythema of 13
isomorphic response 21
lesions of 17, 17
and localized hyperpigmentation 301, 302
and the nails 276, 277
and the scalp 275
treatment 147
lichen sclerosus et atrophicus 83
lichen simplex chronicus (circumscribed
neurodermatitis) 11921, 120, 131, 132
lichenication 19, 20, 20, 21
in atopic dermatitis 107, 1078, 109, 228, 230
in infancy 228, 228, 230
in lichen simplex chronicus 120, 120
lichenoid bands 209
lichenoid purpuric eruption 87
lip-licking cheilitis 233, 233
lipid histiocytes 262, 267, 287
lipocortin 307
lipomas 200
lithium succinate 116
lupus erythematosus 7880
chronic discoid lupus erythematosus (CDLE)
7980, 80
and sun exposure 34
systemic lupus erythematosus (SLE) 789,
78, 79, 163
in pregnancy 240
lupus pernio 48
lupus vulgaris 467
Lyme disease 49
lymphangioma circumscription 195, 195
lymphoedema 164
lymphomas of the skin (cutaneous T-cell
lymphoma) 2245
mycosis fungoides 2245, 225
Szary syndrome 225
lymphoreticular diseases 101
macular amyloidosis 262, 263
macules 15, 16
in lentigo maligna 219
in neurobromatosis 256, 301, 301
in PeutzJeghers syndrome 292
Madura foot 43
malathion 63, 64
malignancy
skin markers of 2815, 282
acanthosis nigricans 283, 283
acquired ichthyosis 284, 285
bullous pemphigoid 284
dermatomyositis 2845
erythema gyratum repens 283, 284
gurative erythemas 285
necrolytc migratory erythema 2812, 282

skin metastases 284, 284
malignant disease of the skin 101, 20726
in AIDS patients 99, 100, 209, 224
and chronic photodamage 29
increasing prevalence of 207
lymphomas 2245
melanoma skin cancer 21924
differential diagnosis 220
juvenile 194, 194
lentigo maligna 21920, 219, 236
malignant melanoma 17, 193, 219, 22023,
221, 221, 223, 236
neoplastic disorders of mesenchymal
elements 2234, 223
non-melanoma skin cancer 20719
basal cell carcinoma 17, 132, 176, 182,
21417, 215, 21516, 236
basal cell naevus syndrome 21718
Bowens disease 132, 21011, 211
keratoacanthoma 214, 214
pathology 209
solar keratoses 2, 20710, 207, 208, 236
squamous cell carcinoma 17, 141, 176, 182,
21114, 212, 213, 236
xeroderma pigmentosum 21819, 219
and photochemotherapy 141, 315
malignant melanoma 22023
acral lentiginous melanoma 221, 222
and displastic naevus syndrome 193
in the elderly 236
epidemiology 2223
and lentigo maligna 219
nodular (NMM) 220, 221, 222
secondary satellite lesions 222
spread (local/regional/distant) 222
supercial spreading (SSMM) 220, 221, 222
treatment 223
management of skin disease 30316
see also specic techniques
phototherapy 31415
psychological aspects of skin disorder 3035
skin disability 305
surgical aspects 30911
systemic therapy 31114, 31213
topical treatments 3059
Marfans syndrome 173
mast cell naevus (mastocytoma) 201
mastocytosis (urticaria pigmentosa) 2012, 202
juvenile 202
mattresses, ripple type 179
mechanical stimuli 256
mefenamic acid 95, 95
Meissner corpuscle 8
melanin 2956, 297
and comedones 150, 150
forms of 296
eumelanin 296
phaeomelanin 296
and hyperpigmentation 299
and solar UVR 25, 28
synthesis 56, 222, 295, 296
melaninuria 222
melanocyte-stimulating hormone 14, 238, 295
melanocytes
brownblack pigmentation 13, 14
in the elderly 234, 235
in hypopigmentation 297
in pregnancy 238
structure/functions 4, 56, 6, 2956, 2956
melanocytic naevi (moles) 18892, 189
324
acquired 189, 19091, 191

compound naevi 189, 192
congenital 189, 190, 190, 191
bathing trunk naevi 190
cape naevi 190
dermal cellular naevi 189, 1912
junctional naevi 189, 191, 192
in pregnancy 238
treatment 204
melanoma skin cancer 21924
juvenile 194, 194
lentigo maligna 21920, 219, 236
malignant melanoma 17, 193, 219, 22023,
221, 221, 223, 236
neoplastic disorders of mesenchymal elements
2234, 223
melanosomes 295, 296, 296
melasma (chloasma) 238, 239, 301, 302
meningococcaemia 86
mentholated calamine preparations 68, 240
mepacrine 94
metabolic disorders 25966
see also specic disorders
metastatic disease 284, 284
methaemoglobinaemia 300
methotrexate 313, 314
for pemphigus 92
for pityriasis rubra pilaris 143
for psoriasis 13940
5-methoxy psoralen 141
8-methoxy psoralen 141, 315
metronidazole 167, 168
miconazole 116
microlariae 69, 70
Microsporon 39
M. canis 39, 41
milia 203, 203
miliaria crystallina 34
miliaria profunda 34
miliaria rubra 34
minocycline
for rosacea 167
side effects 14, 160
for swimming pool granuloma 47
minoxidil 271, 273
minoxycycline 300
mites
bites 67, 67
Demodex folliculorum 166
moles see melanocytic naevi
molluscum contagiosum 556, 55, 56, 98, 98
molluscum sebaceum (keratoacanthoma) 214,
214
Mongolian spots 192, 301
monilethrix 276, 276
monochromators 33
morphoea 823, 82
generalized 83
lichen sclerosus et atrophicus 83
mosquito bites 65, 66
Munro microabscesses 137
mupirocin 44, 113, 309
mycosis fungoides 131, 2245, 225
myxoedema, pretibial 2856, 285
naevi
see also melanocytic naevi
Beckers naevus 186, 186
capillary naevus 1947
of collagen and elastic tissue 2001
Index
degenerative changes in 1924

blue naevi 1923, 192
displastic naevus syndrome 193, 194
juvenile melanoma 194, 194
epidermal 185, 185
halo naevus 298
mast cell naevus 201
naevus of Ito 301
naevus of Ota 301, 301
naevus sebaceous 186, 186
naevus unius lateris 185, 185
spider naevus 239, 239, 293
strawberry naevus 195, 195
nail matrix 269
nail plate 269
nails
disorders of 268, 2769
brittle nails 278
fungal infections 41, 41
lichen planus 144, 145
onycholysis 41, 129, 276, 2778
onychorrhexis 278
paronychia 277, 277
psoriasis 129, 129
ridging 276, 277
ringworm of 278, 279
in systemic disease 278
thimble-pitting 129, 276, 276
whitening 292, 293
yellow nail syndrome 278, 279
nalidixic acid 94
napkin rash 22830
erosive napkin dermatitis 229, 229
seborrhoeic dermatitis 22930
naproxen 94
necrobiotic disorders 2656
granuloma annulare 265, 265, 266, 287
necrobiosis lipoidica 266, 286, 287
necrolytic migratory erythema 2812, 282
Nelsons syndrome 14, 299
neomycin 113
neoplastic disorders of mesenchymal elements
2234
dematobromasarcoma 224
Kaposis sarcoma 99, 100, 2234, 223
nerve structures, dermal 78, 8
neural tumours 199200
neurilemmoma 200
neurobroma 22, 199200, 199
neurobromatosis (Von Recklinghausens disease)
16, 199200, 199, 256, 257, 301, 301
neuromas 200
plexiform 256
neuropathic ulceration 173, 179, 179
nevirapine 100
nickel dermatitis 123
nicotinic acid 291
nifedipine 34
nociceptive reex, failure of 287
nodules 16, 150
crateriform 214, 214
in malignant melanoma 221, 221
non-bullous ichthyosiform erythroderma
(NBIE) 24950, 250
non-steroidal anti-inammatory drugs
(NSAIDs) 93, 94
nutrition 291
nystatin 43
oedema 1718, 18
in eczema 105, 106
in venous hypertension 1745
oil folliculitis (oil acne) 27

old age 2337
ageing process 234
skin changes in 2345
skin disease in 2357
olive oil 231
onchocerciasis 6970, 69
onycholysis 41, 129, 276, 2778
onychorrhexis 278
opioid drugs 74, 94
oral contraceptive pill 238
orf (contagious pustular dermatitis of sheep)
56, 56
oriental sores 49
osteoporosis, senile 291, 292
oxygen therapy 93
oxypentifylline 34
oxytetracycline 160
Paccinian corpuscle 8
pachyonychia congenital 256
pain 21
palm
and the disabling effects of skin disease 23
eczema of 108, 108, 109
hyperlinear 108, 108
in pregnancy 239
psoriasis of 132, 132
palmoplantar pustulosis 134, 134
papular urticaria 678, 68
papules
in acne 150, 151, 289
in angiokeratoma 196, 196
in Dariers disease 254, 254
in granuloma annulare 265, 265
horny red in keratosis pilaris 246, 246
in mastocytosis 202, 202
in perioral dermatitis 1689, 169
in rosacea 163, 163
parakeratosis 136
parapsoriasis 225
parasitosis, delusions of 3056
paronychia 277, 277
patch testing 121, 124, 124
peaches and cream complexion 286
peau dorange 285
pediculocides 63, 64, 65
pediculosis 635
pediculosis capitis (head lice) 634, 63
pediculosis pubis (pubic lice, crab lice) 645,
65
pemphigus 912, 91
benign mucous membrane pemphigoid 89
bullous/senile pemphigoid 18, 18, 19, 889,
88, 89, 284
chronic benign familial 255
pemphigoid gestationis 241, 241
pemphigus erythematodes 92
pemphigus foliaceous 92
pemphigus vegetans 92
in pregnancy 240, 241, 241
penicillamine 82, 94, 95
penicillin
hypersensitivity to 74, 93, 94
for Lyme disease 49
for syphilis 104
penicillin V 44, 45
pentamidine 50
periodic acid-Schiff reagent 38, 38, 39
perioral dermatitis 163, 1689, 169
peripheral vasodilating drugs 178
persistent pigmented purpuric eruption 87, 87
PeutzJeghers syndrome 292, 301
phaeomelanin 296
phenothiazines 94, 300

photochemotherapy 31415
see also photochemotherapy with ultraviolet
radiation of the A type
for polymorphic light eruption 33
for psoriasis 141, 142
for vitiligo 298
photochemotherapy with ultraviolet radiation of
the A type (PUVA) 101, 315
for alopecia areata 273
for localized hypopigmentation 298, 299
for pretibial myxoedema 285
for psoriasis treatment 141, 142
side effects 141, 142, 315
for vitiligo 298
photodamage, chronic (photoageing) 2934
dermal 29, 30
dermatoses 314
epidermal 29
prevention 2931
photodermatoses 314
chronic actinic dermatitis 32, 32
conrmatory tests for 33
Hutchinsons summer prurigo 33
photosensitivity reactions 312, 31
polymorphic light eruption 323, 33
sweat rashes 334
photodysplasia, epidermal 29
photopatch tests 33
photoprovocation tests 33
photosen 32
photosensitive dermatitis 291
photosensitivity reactions 312, 31
due to drugs 32, 945, 94, 95
in erythropoietic porphyria 261
in porphyria cutanea tarda 25960
photosensitizing agents 312, 32
phototoxic reactions 32
physical appearance, abnormal 213, 3035
piebaldism 297
pigment darkening method 31
pigmentation 1214
disorders of 295302
in acanthosis nigricans 283, 283
due to toxic substances 27
hyperpigmentation 27, 109, 289, 289, 296,
299302, 300
hypopigmentation 27, 48, 109, 2969, 299
pigmentary incontinence 13
in pregnancy 238, 239
pilomatrixoma 188
pimozide 305
pituitaryadrenal axis suppression 307
pityriasis rosea 17
pityriasis rubra pilaris 1423, 143
pityriasis versicolor 379, 38
in AIDS patients 98, 99, 100
in Cushings syndrome 289
macules 15, 16
Pityrosporum ovale 37, 98, 99, 115, 157
plaques 1516, 17
granulomatous 46
in necrobiosis lipoidica 286, 287
in pretibial myxoedema 285, 285
psoriatic 13, 13, 128, 129
podophyllin 55
polyarteritis nodosa 86
polycythaemia rubra vera 1634, 293
polyethylene beads 159
polymorphic light eruption 323, 33
polymorphs 156, 156
325
Index
polymyositis 83
pores 2, 3, 34
porphyrias 25961
enzyme defects of 259, 260, 261
erythropoietic porphyria 261
erythropoietic protoporphyria 261, 300
hepatic 25960
porphyria cutanea tarda (PCT) 25960, 260,
261
porphyria variegata 261
port-wine stains 194, 194
potassium permanganate solution 113, 177
povidone iodine 309
prednisone 92
pregnancy 23842
effects on intercurrent skin disease 240
effects of intercurrent skin disease on the
fetus 24041
physiological changes in the skin 23840
skin disorders in 241
pressure sores 179
procainamide 95
Propionibacterium acnes 157
protein C deciency 173
prurigo nodularis 120, 120, 304
prurigo papules 19, 20, 21
pruritus (itching) 2021
in AIDS patients 99
in atopic dermatitis 107
in old age 235
in pregnancy 240, 241, 241
as sign of diabetes 288
systemic causes of 293
pseudoacanthosis nigricans 283
pseudoepitheliomatous hyperplasia 120
pseudomycelium 38
pseudopelade 275
psoralen drugs 141, 315
psoriasis 2, 12, 12842
aetiology 1378
in AIDS patients 100
clinical variants 1326
arthropathic psoriasis (arthritis mutilans)
1356, 136
erythrodermic psoriasis 4, 133, 139
exural 129, 130
guttate psoriasis 1323, 133
napkin psoriasis 133, 230, 231
pustular psoriasis 1345, 134, 135, 137, 139
denition 128
dehydration in 4
erythema of 13, 13
genetic inuences 131
in immunocompromised patients 100, 101
and the isomorphic response 21, 130
and keratinization 5
lesions of 1516
and the nails 276, 276
natural history/epidemiology 13031
painful 21
and the palms 132, 132
pathology/pathogenesis 1367
epidermal thickening 136, 136, 137, 138
inammatory component 137, 138
vascular component 137
scaling of 15
and sun exposure 34
psychological aspects of skin disorder 213,
3035
psychotropic drugs 94
pus 45
pustular bacterid 135
pustules 150
pyoderma gangrenosum 18081, 180
pyogenic granuloma 197, 197
pyrazinamide 46
quinolones 160
radiotherapy
for basal cell carcinoma 217
for Kaposis sarcoma 224
for lentigo maligna 220
for squamous cell carcinoma 213
rashes
in allergic contact dermatitis 1223
in allergic vasculitis 84
blistering 94
in erythema multiforme 76
in exanthematic eruptions 94
infantile 22730
lichenoid 94, 119
lupus erythematosus-like 95
morbilliform 94
photosensitivity type 323, 33, 945, 94, 95
in pregnancy 241, 241
in primary irritant dermatitis 121
in rosacea 163
in scabies 589
sweat rashes 334
urticarial 94
in vascular eruptions 94
Raynauds phenomenon 34, 34, 80, 81, 82
recombinant interferons 55
recombinant interferon-alpha 2B 100
reectance spectroscopy 13
Refsums syndrome (heredopathia atactica
neuritisformis) 253
Reiters syndrome 102
renal allografts 101
renal failure 293, 300
reticulohistiocytic proliferative disorders 2667
retinoids 223
systemic 311, 312
for bullous ichthyosiform erythroderma
2512
for the harlequin fetus 253
for non-bullous ichthyosiform
erythroderma 250
for pityriasis rubra pilaris 143
for psoriasis 140
for sex-linked ichthyosis 249
for squamous cell carcinoma 21314
teratogenicity of 140, 140, 160, 161, 240,
250, 311, 312
for xeroderma pigmentosum 218
topical
for acne 159
for chronic photodamage 29
for Kaposis sarcoma 224
for psoriasis 139
rhinophyma 164, 165, 166, 167
rifampicin 46, 49
ringworm see tinea infections
river blindness 69
rosacea 1628
aetiopathogenesis 1667, 167
complications 1645, 165
denition 162
326

pathology 166, 166
and sun exposure 34
treatment 1678
salicylic acid preparations
for acne 157
for infants 227, 231
for molluscum contagiosum 56
for viral wart infections 55
saline solution 177
sarcoidosis 478, 478
scabies 5863
in AIDS patients 100
burrows 59, 59, 6061
clinical features 5960, 59, 60, 61
diagnosis 6061, 61, 62
dog scabies 63
mites 61, 61
Norwegian scabies 60, 61
pruritus in 20
sites of predilection 59, 60
treatment 612, 62
scaling 1415, 15, 244
see also xeroderma
in atopic dermatitis 108
in autosomal dominant ichthyosis 246, 247,
247
in bullous ichthyosiform erythroderma 251,
251
differential diagnosis of 208
in lamellar ichthyosis 252
in non-bullous ichthyosiform erythroderma
249, 250
in seborrhoeic dermatitis 11415, 114
in sex-linked ichthyosis 248, 248, 249
scalp
lichen planus and the 275
tinea capitis of 41, 41
scanning electron microscope (SEM) 23
scarring 26
in acne 150, 151, 156
in congenital alopecia 268
from excision of small tumours 311
hypertrophic 1978, 198
ice-pick 150, 152
keloid 198, 198, 311
nodular 150, 151
in scarring alopecia 275, 275
Schambergs disease 87, 87
scleroderma 80, 823
scratch and prick test 111
scurvy 291
sebaceous gland hyperplasia 188, 189, 234
sebaceous glands 8, 10
sebocystoma multiplex (steatocystoma
multiplex) 204
seborrhoeic dermatitis see eczema, seborrhoeic
dermatitis
seborrhoeic warts (basal cell papillomas) 1845,
1845, 185, 205, 236
sebum 89
constituents 157
secretion
increased (seborrhoea) 149, 150, 157
reduced 158, 159, 16061, 235
sebum secretion rate 157
selenium disulphide shampoo 39
senile angioma (Campbell de Morgan spot,
cherry angioma) 196, 196
Index
senile osteoporosis 291, 292

senile pemphigoid (bullous pemphigoid) 18, 18,
889, 88, 89, 284
senile pruritus 20
senile xerosis 20
sensitization 125
see also photosensitivity reactions
Szary syndrome 225
shagreen patches 200, 256
shave excisions 204, 310
shock, anaphylactic 67, 93
signs of skin disease 1220
alterations in skin colour 1214
alterations in skin surface 1415
oedema/uid-lled cavities/ulcers 1719
secondary changes 1920
size/shape/thickness of lesions 1517
silver preparations, topical 300
skin scrapings 61, 61
potassium hydroxide (KOH) treated 131
skin snips 69
skin surface biopsy
for pityriasis versicolor 38, 38
for ringworm 39, 39
for scabies 61, 61
technique 38
skin surface contour measurement 15
skin surface lipid 157, 157
skin tags 283, 283
sodium stibogluconate 50
sodium thiosulphate solution 39
solar elastosis 28, 29, 30, 141
solar keratoses (actinic keratoses) 2, 20710
denition 207
in the elderly 236
pathology 209
treatment 210
soles of the feet 23
spectroscopy 13
spironolactone 161
sporotrichosis 43
squamous cell carcinoma (squamous cell
epithelioma) 21114
in the elderly 236
risk of in ultraviolet radiation therapy 141
and solar keratoses 209
treatment 21314
and ulceration 176, 182
staphylococcal scalded skin syndrome (toxic
epidermal necrolysis) 93, 2323
Staphylococcus
S. aureus 44, 45, 232
S. epidermidis 157
star system 31
stavudine 100
steroid sulphatase deciency 247, 248, 249
steroids 82
see also corticosteroids; specic drugs
systemic 68
for allergic vasculitis 86
for alopecia areata 273
for dermatomyositis 84
for pemphigus 92
topical 273
StevensJohnson syndrome see erythema

multiforme
stings see insect bites/stings
stork mark 194
stratum corneum (horny layer)
ageing 234
cryostat section of 3, 3
dehydration due to disordered 4
functions 4, 5, 25, 244
infections 37
and keratinization disorders 1415
mechanical properties 4
psoriatic 136
replacement time (turnover time) 14
structure 2, 34
toxic substance damage 26
streptococcal antigens 85
Streptococcus 44, 45
stress 304
striae distensae 239
in Cushings syndrome 2889, 289
due to topical corticosteroid use 308, 308
striae gravidarum (stretch marks) 239, 239
structure/functions of skin 1, 211
adnexal structures 811
dermis 68
epidermis 1, 46, 5
stratum corneum 2, 34
surface area of the skin 1, 2
surface of the skin 23, 1415, 14
SturgeWeber syndrome 194
styes 165
sulphaemoglobinaemia 300
sulphonamides 160
eruptions due to 93, 94, 95
sulphur preparations
for acne 157, 159
sun lamps 141
sun protection factor (SPF) 30
sunburn 28
sunscreens 3031, 168
suntans 25
Suramin 70
surface area of the skin 1, 2
surface of the skin 23, 1415, 14
surgical aspects of the management of skin
disease 177, 30911
see also specic techniques
ablative procedures 310
cryotherapy 50, 55, 204, 210, 310
curettage and cautery see curettage and cautery
excision see excision
laser treatment 310
shave excisions 204, 310
swabs 182
sweat glands
ageing of 235
apocrine 11, 186
benign tumours of 1868, 187
eccrine 187
pores 2, 3, 34
structure 2, 3, 911, 10
sweat rashes 334
sympathectomy 178
symptoms of skin disease 2024
disabilities of skin disease 213
painful skin disorders 21
pruritus 2021
syphilis 1034, 103
chancre 103
diagnosis 104
treatment 104
and ulceration 103, 172, 181
syringoma 186, 187, 187
systemic diseases and the skin 28194
androgenization 28990, 290
diabetes 2868, 286
endocrine diseases 2858
gastrointestinal diseases 292
hepatic disease 2923, 293
nutrition 291
pruritus 293
skin markers of malignancy 2815, 282
systemic sclerosis 8082, 81
manifestations of 8081, 81
pathology 81
treatment 82
systemic therapy 31114, 31213
see also specic drugs
antifungals 314, 315
azathioprine 313, 314
comparison with topical treatments 310
corticosteroids 311
cyclosporin 313, 314
Dapsone 313, 314
methotrexate 313, 314
retinoids 311
T-cells 97, 111, 125
tacalcitol 138
tachyphylaxis 112
tacrolimus 112
tagretin 100
tar preparations
for lichen simplex chronicus 121
for psoriasis 138
tartrazine 94
tattooing, hyperpigmentary 27, 301
tazarotene 139, 141
telangiectasia 29, 30, 174, 174
ataxia telangiectasia 101
in rosacea 1623, 162, 166, 168
telangiectasia macularis eruptiva perstans of
Parkes Weber 202
telangiectatic macules 81, 81
telogen efuvium 273
teratogenicity, of systemic retinoids 140, 140,
160, 161, 240, 250, 311, 312
terbinane 42, 314, 315
testosterone 270
tetracyclines
eruptions due to 94, 95
systemic
for acne 15960
for perioral dermatitis 169
for rosacea 167
topical 159
theques 190, 191
thermal homeostasis 25
thiazide diuretics 94
thimble pitting 129, 276, 276
thinning of the skin 288, 288, 308
thioavine T 262
thiopurine methyl transferase deciency 314
thyroid acropachy 285
thyroid disease 2856, 293
tick bites 67
tinea (ringworm) infections 3943
differential diagnosis of 11516, 131, 131
lesions of 1617, 16
tinea capitis 39, 41, 41, 42
tinea corporis 3940, 39
327
Index
tinea (ringworm) infections cont.

tinea cruris (groin ringworm) 40, 40
tinea incognito 42, 42
tinea manuum 40
tinea pedis 40
interdigital 40
plantar 40
vesicular 40
tinea unguium 41, 41, 42, 42, 43
nail infections 278, 279
due to topical corticosteroid use 308
treatment 423
topical treatments 3059
see also specic drugs/treatments
antimicrobial agents 309
comparison with systemic therapies 310
corticosteroids 3078, 307, 308
emollients 3067
how much to prescribe 3056
side effects 306, 306
toxic epidermal necrolysis (staphylococcal
scalded skin syndrome) 93, 2323
toxic substances 267
transplant patients 100
transudate 17
trephines (punch biopsies) 309
Treponema pallidum 103
Treponema pallidum haemagglutination assay 104
tretinoin 159, 232, 240, 255
trichloracetic acid 264
trichoepithelioma 188
Trichophyton 39, 40
T. mentagrophytes 39, 40, 41
T. rubrum 39, 40, 41
T. schoenleini 41
T. verrucosum 40
trichorrhexis nodosa 275, 275
trichotillomania (hair pulling) 2723, 274,
274
trimethoprimsulphamethoxazole 47
trimethoxy psoralen 141
triple response, exaggerated 72, 73
tuberculides 46
tuberculosis 467, 99, 172, 181
tuberculosis verrucosa cutis (warty tuberculosis)
46
tuberous sclerosis (epiloia) 2001, 201, 256
tumours 16, 17
benign 1838
of epidermal origin 1836, 1846, 185,
205, 236
of hair follicle origin 188
leiomyoma 198
lipoma 200
neural 199200
of sweat gland origin 1868, 187
glomus 21, 197
in neurobromatosis 256, 257
in old age 236
painful 21
pedunculated 16
small, excision of 31011
tylosis 2556, 255
tyrosinase 296, 297
ulceration 19, 17182
aetiology 173, 18082
in bacterial skin infections 103, 172, 176, 181
in basal cell carcinoma 176, 182, 215, 215, 215
Buruli ulcer 47
in capillary angioma 195

in chancroid 102
Chicleros ulcer 4950
decubitus 173, 1789, 179
in diabetes 287, 287
diagnosis and assessment 182
due to cutaneous tuberculosis 46
ischaemic 173, 1778
neuropathic 173, 179, 179
oriental sores 49
painful 21
perforating 287, 287
rodent ulcer 215, 215, 215
snail-trail ulcers 103
vasculitic 173, 181, 181
venous 1256, 1737, 173, 175, 178
ultrasound Doppler blood ow 182
ultraviolet radiation (UVR)
see also photochemotherapy;
photochemotherapy with ultraviolet
radiation of the A type
and ageing 234
and albinism 296, 297
and basal cell carcinoma 216
and chronic photodamage 29
injury from 278, 28
and the Langerhans cells 6
and malignant melanoma 222
and melanin 5, 6, 25, 28, 295, 296
narrow-band UVR 141
and photodermatoses reactions 312, 34
photopatch tests for 33
sensitivity to 28
see also photosensitivity reactions
and solar keratoses 209
UVA 27, 28, 28, 3031, 32
UVB 27, 28, 30
UVC 27, 28
uroporphyrins 259, 260
urticaria 715, 72
associated with atopic dermatitis 110
causes 73, 73
cholinergic 74
drug-induced 74
oedema in 17
papular 678, 68
physical 734
cold urticaria 73, 73
dermographism 17, 17, 72, 73, 74
pressure urticaria 73
solar 74, 74
pruritus in 21
and stings 745
treatment 75
urticaria pigmentosa 2012, 202
urticaria vasculitis 72
valves, venous 174, 174
varicosities 174, 174
vascular ow promoters 178
vascular malformations (angioma) 1947
capillary 195, 195
senile 196, 196
vasculature 234
dermal 7, 7
vasculitic ulceration 173, 181, 181
vasculitis group of diseases 78, 847, 86
allergic vasculitis (HenochSch
nlein
purpura) 846, 85
capillaritis 87, 87
328
nodular vasculitis 86
polyarteritis nodosa 86
Vaseline 264
venereal disease, dermatological aspects 1024
chancroid 103
gonorrhoea 102
Reiters syndrome 102
syphilis 99, 1034, 103, 172, 181
Venereal Disease Reference Library (VDRL) test
104
venesection 260
venous drainage 1767
venous hypertension 1737, 174, 175, 178
venous ulceration 1256, 1737, 173, 175, 178
vesicants 27
vesicles
in eczema 18, 18
in herpes zoster 19
viral skin infections 5056
chicken pox 51, 52, 241
herpes simplex 5051, 51, 99, 100, 111, 241
herpes zoster 19, 21, 51, 523, 52, 99, 100
molluscum contagiosum 556, 55, 56, 98, 98
orf 56, 56
viral warts 535, 53, 54
vitamin A (retinol) 291
vitamin C (ascorbic acid) 291
vitamin D 291
vitamin D analogues 138, 139
vitiligo 2978, 298
Von Recklinghausens disease
(neurobromatosis) 16, 199200, 199, 256,
257, 301, 301
Von Zumbusch disease (generalized pustular
psoriasis) 1345, 135, 139
Waardenburgs syndrome 297
warts 241
and drug-induced immunodeciency 101, 101
seborrhoeic 1845, 1845, 185, 205, 236
viral 535, 53, 54
wasp stings 67
Wassermann reaction (WR) 104
white dermatographism 109, 109
Wickhams striae 144, 144
winter itch 245
Woods light 38, 41
wound healing
delayed 1723
in the elderly 234
event sequence following 171, 172
important factors 1713
of ulceration 17182
xanthogranuloma, juvenile 2667
xanthomata 2624, 2878, 287
eruptive 264, 265
xanthelasma 264, 264
xanthoma disseminatum (XD) 2667
xanthoma tuberosum 264, 264
xeroderma 108, 2456, 284
causes 245, 245
keratosis pilaris 246, 246
treatment 246
xeroderma pigmentosum 21819, 219
zidovudine 100
ZiehlNielsen stain 48

Roxburgh Common Skin Diseases

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ROXBURGHS

Common Skin Diseases

A member of the Hodder Headline Group London

First published in Great Britain in 2003 by

1 An introduction to skin and skin disease

2 Signs and symptoms of skin disease

3 Skin damage from environmental hazards

5 Infestations, insect bites and stings

6 Immunologically mediated skin disorders

7 Skin disorders in AIDS, immunodeciency and venereal disease

9 Psoriasis and lichen planus

10 Acne, rosacea and similar disorders

11 Wound healing and ulcers

12 Benign tumours, moles, birthmarks and cysts

13 Malignant disease of the skin

14 Skin problems in infancy and old age

15 Pregnancy and the skin

16 Disorders of keratinization and other genodermatoses

17 Metabolic disorders and reticulohistiocytic proliferative disorders

18 Disorders of hair and nails

19 Systemic disease and the skin

21 Management of skin disease

Skin structure and function

Figure 1.1 Simple three-dimensional plan view of the

Figure 1.2 Diagram of the basic structure of the

An introduction to skin and skin disease

Skin structure and function

THE SKIN SURFACE

Skin structure and function

Figure 1.3 Diagram of the skin surface to show sweat

Figure 1.4 Scanning electron micrograph of stratum

Figure 1.5 Photomicrograph of a corneocyte (150).

Figure 1.6 Photomicrograph of cryostat section of

of desquamation (Fig. 1.4). Corneocytes are approximately 35 m in diameter,

THE STRATUM CORNEUM

An introduction to skin and skin disease

The orderly release of corneocytes at the surface in the process of desquamation

Skin structure and function

The Basal Lamina

Figure 1.8 Diagram to

An introduction to skin and skin disease

Figure 1.9 Diagram to

Skin structure and function

The amorphous substance consists

Figure 1.11 Diagram to show the

polypeptide chains arranged in a triple helix format in which hydroxyproline

An introduction to skin and skin disease

THE ADNEXAL STRUCTURES

Skin structure and function

Figure 1.13 Diagram to show hair cycle.

Hair shaft in hair

Figure 1.14 (a) Diagram to show general arrangements

An introduction to skin and skin disease

Figure 1.15 Photomicrograph to show

Figure 1.16 (a) Photomicrograph to show tubular

Langerhans cells are dendritic, bone marrow-derived

Signs and symptoms

Alterations in the skin surface

The size, shape and thickness of skin lesions

Oedema, fluid-filled cavities and ulcers

Symptoms of skin disorder

Skin disorders may be generalized, localized to one or several sites of abnormality

Alterations in skin colour

Alterations in skin colour